World Health Organization EUR/QCPH 08 32 03
Drug Reimbursement Pilot System, Kutaisi, Georgia
1998 Annual Report
Frans Stobbelaar Economic Adviser
WORLD HEALTH ORGANIZATION
Special Project for Newly Independent States
A collaboration of the Drug Action Programme (EDM/DAP) and Programme for Pharmaceuticals (EURO)
1999 EUR/QCPH 08 32 03 ENGLISH ONLY UNEDITED E67886
EUROPEAN HEALTH21 TARGET 16
MANAGING FOR QUALITY OF CARE
By the year 2010, Member States should ensure that the management of the health sector, from population-based health programmes to individual patient care at the clinical level, is oriented towards health outcomes (Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)
ABSTRACT
Concerned with the high levels of patients’ payments for drugs, the Ministry of Health of Georgia considered a drug reimbursement system – however few funds might be available for it – a useful instrument to improve affordability of drugs and access to primary health care services. During 1996–1997, a new drug reimbursement concept (Drug Polis) was developed by the WHO Special Project for Newly Independent States (NIS) in collaboration with the Georgian health authorities, and tested in Kutaisi since October 1997. This new concept is a voluntary insurance scheme, for which a fixed participation fee (the price of a booklet) is levied regardless of income. Benefits are: 20% reduction in the fee for visiting a doctor, 10% discount on prescription drugs below an accumulated annual expenditure of 100 Lari, and 50% reimbursement for all additional prescription drugs per year. After a slow start, 12 000 booklets were sold by the end of 1998. The pilot scheme shows that a comprehensive drug reimbursement system appeals to two thirds of the population. This system, where benefits increase with growing drug expenditure, can also be financially feasible and well managed in the Georgian setting. It is probably less viable as a voluntary independent scheme and might be better incorporated in a health insurance scheme or primary health care package. The public appreciated the fixed premium or fee per insured person, independent of income. This is useful knowledge for other areas of health insurance. It is recommended that Drug Polis should be continued in a wider regional setting, while other pilot sites, preferably in combination with health insurance funds or an integrated primary health care project, will eventually improve the affordability of drugs in Georgia and inspire other NIS.
Keywords
REIMBURSEMENT MECHANISMS DRUG COSTS ORGANIZATION AND ADMINISTRATION ECONOMICS, PHARMACEUTICAL INSURANCE COVERAGE INFORMATION SYSTEMS PROGRAM EVALUATION GEORGIA
© World Health Organization – 1999 All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors.
This document was text processed in Health Documentation Services WHO Regional Office for Europe, Copenhagen
CONTENTS
Page
1. Introduction ...... 1
2. Kutaisi and the Imereti Region...... 1 2.1 Background information ...... 1 2.2 Demographic, social and health situation...... 2
3. Drug reimbursement concept...... 2 3.1 The problem ...... 2 3.2 Objectives...... 3 3.3 Design of the system ...... 3 3.4 Final concept of the pilot system...... 7
4. Implementation...... 8 4.1 Starting up ...... 8 4.2 Organization...... 9 4.3 Administration...... 10 4.4 Information system...... 10 4.5 Communication and promotion...... 10 4.6 Political and local support...... 11
5. Results ...... 11 5.1 Membership development ...... 11 5.2 Financial results...... 13 5.3 Other results ...... 14
6. User survey...... 14 6.1 Methodology ...... 15 6.2 General opinion of members and non-members ...... 15 6.3 Membership...... 16 6.4 Conclusions – the public view...... 17
7. Conclusions and recommendations for further development ...... 17 7.1 Conclusions ...... 17 7.2 Lessons learnt...... 18 7.3 Recommendations ...... 20 Annex 1. Distribution of drug costs as a basis for risk pooling parameters Annex 2. Administrative guidelines Annex 3. Pharmacy administration record Annex 4. Booklet Annex 5. Kutaisi communication plan Annex 6. Communication samples Annex 7. "Drug Polis" Kutaisi, 1998, sociological research, full report Annex 8. Drug Polis Information System Annex 9. List of products for reimbursement
Acknowledgements
Name Drug Polis
Design The Drug Polis pilot system in Kutaisi City was designed by the WHO Special Project on Pharmaceuticals for Newly Independent States: Frans Stobbelaar (Economic Adviser), Nata Menabde (Project Manager).
Local organization Drug Polis is a non-profit foundation established by 50 citizens of Kutaisi city and the city administration. The Drug Polis project in the foundation is led by Ramaz Kerdzaya and David Mikeltadze. Technical and administrative support is provided by Gocha Giorgadze. Permanent (and valued) political and financial advice is provided by George Kelbakiani, Head of Imereti Finance Department.
Steering group A steering group accompanying the implementation of Drug Polis consists of representatives of: the Georgian Ministry of Health, the Georgian Parliamentary Committee for Social and Medical Affairs, the health authority of Imereti Region, the Kutaisi city administration, and the government of Imereti Region.
Local support Drug Polis has received substantial support from regional and local political leaders, particularly Teimuraz Shashiashvili, Governor of Imereti Region, Badri Melkadze, Mayor of Kutaisi, and Dodo Shelia, Head of the Health Department of Imereti Region.
The efforts of local municipalities in making the booklets available to the population have been essential to the project’s initial success.
Participating pharmacies Sanimusho Pharmacy, Pharmacies Nos. 19 and 20, Kura-mediana Pharmacy.
Participating polyclinics Polyclinic of No. 1 City Hospital, Polyclinic No. 5 of Avtokarkhana, Children’s Polyclinic No. 3, Children’s Polyclinic at Sulkhan Saba Street 19.
Thanks to: WHO headquarters: Jonathan Quick, German Velasquez, Pascal Brudon and Guy Carrin; World Bank: Laura Rose and Tomas Paalu; and in Georgia: Avtandil Djorbenadze, Amiran Gamkrelidze, Marina Giorgobiani, Lado Giorgadze, Roman Makharadze, Kote Barkaya, Tamara Kezeli, George Kelbakiani, Marina Barkaya and Rusudan Giorgobiani for their valuable comments that have contributed to Drug Polis.
Report WHO Regional Office for Europe (Frans Stobbelaar and Nata Menabde).
Financial support The project is financially supported by the United Kingdom Department for International Development.
EUR/QCPH 08 32 03 page 1
1. Introduction
At the end of 1995, the Ministry of Health in Georgia raised the idea of developing a new drug reimbursement system. The Ministry was concerned about the high levels of patients’ payments for drugs, which diminished the access to essential drugs for large groups of the population that did not benefit from state programmes (free drugs). The Ministry considered that a drug reimbursement system, however few funds might be available for it, would be a useful instrument to increase access to, and improve the affordability of, drugs while at the same time making the primary health care system more accessible. Fundamental questions were raised, such as: Who should pay for drugs? Which drugs should be paid for? How much should be paid? How should payment be made?
In the course of 1996 and 1997, a concept was developed by the WHO Special Project for the Newly Independent States (NIS), in close collaboration with the Georgian health authorities, that was considered to be potentially feasible in the current economic situation in Georgia. WHO and the Ministry of Health decided to test this concept in a realistic pilot situation. The Ministry of Health designated the city of Kutaisi in western Georgia for this purpose. After a series of discussions with local and regional health authorities and the establishment of a project management office, the pilot reimbursement scheme started in October 1997. This document reports on its start-up and first year.
2. Kutaisi and the Imereti Region
2.1 Background information
Kutaisi is an industrial centre in west-central Georgia (Fig. 1) which, under the Soviet system, produced trucks, pumps, mining machinery, textiles (especially silk), foodstuffs and other consumer goods. There is a hydroelectric plant on the Rioni River. It is the second largest town in Georgia after Tbilisi, with a population of approximately 240 000. Kutaisi (the name is derived from “kuata” meaning “stony”) is one of the oldest cities of Transcaucasia and has retained many medieval features. At various periods it has been the capital of successive kingdoms in Georgia. Now it is the capital of Imereti Region.
Fig. 1. Map of Georgia, showing Kutaisi
Kutaisi
EUR/QCPH 08 32 03 page 2
Kutaisi is served by a railway and an airport. The Imereti Road leads from eastern to western Georgia, passing cosy villages scattered about the picturesque slopes of the Surami Range, into the city of Kutaisi. Above the city towers Mount Gabashvili. From its summit there is a wonderful panorama of Kutaisi, with the red-tiled roofs of the old houses nestling among masses of greenery (see title page), the slender arrows of the bridges and white buildings of new residential districts. The most famous of Kutaisi’s many splendid buildings is the majestic Church of King Bagrat, which was built at the beginning of the 11th century.
2.2 Demographic, social and health situation
Some basic data on the demographic, social and health situation in Kutaisi are given in Table 1. The high level of unemployment and very low health budget and income levels are typical of many regions in the NIS. The local and regional health management is, however, up to standard, which is illustrated by two examples: · on the basis of new regional regulations (as national laws did not yet provide the legal basis for such interventions), pharmacy kiosks were removed and illegal sales of pharmaceutical products in market-places stopped; sales of pharmaceuticals are now limited to licensed outlets; · a survey of poverty levels in the city resulted in the identification of 40 000 people, or 17 000 families, as (extremely) poor by international standards; special measures, including a special pharmacy were designed to assist these people.
Table 1. Key data, Kutaisi City
Population: 240 000 Unemployment: >50% Vulnerable groups: 17 000 registered poor and vulnerable families; total approximately 40 000 people Overall budget: 1997: 10 million Lari (US $7.5 million) Health budget: 1997: 200 000 Lari (US $150 000) – approximately 2% of the overall budget
The total municipal budget of Kutaisi in 1997 was 10 million Lari,1 of which health care was 200 000 Lari (2%) – i.e. 0.83 Lari per capita. The take-up rate of the budget was between 30% and 50%, depending on the period. In reality there was only some 0.40 Lari per capita available for health care, which was basically spent on municipal programmes. Although these programmes were not being fully implemented, programmes funded by the central budget were said to be being fairly well carried out.
3. Drug reimbursement concept
3.1 The problem
Hospital drugs are in principle free of charge for patients and covered from state or municipal budgets. The drugs are either provided by donations or through the (former) state wholesaler and
1 1 Lari = an average of approximately US $1.25 in 1996, $1.35 in 1997 and $2.25 at the beginning of 1999.
EUR/QCPH 08 32 03 page 3
A-pharmacies. The state programmes theoretically provide free drugs to the most vulnerable groups of the population and for certain diseases, covering hospital care and, to a limited extent, outpatients. Most outpatients, however, have to pay for their drugs themselves.
Large groups of the population are not covered by any drug reimbursement scheme and do not receive these so-called free drugs. Provision of free drugs through the state programmes is limited, and even for those groups that are covered, the supply does not always work satisfactorily. It often happens that drugs officially available through the state programmes are not in fact available because of the lack of funds and patients – including hospital patients – must buy them at higher prices on the private market.
The main problem is a lack of available funds. Neither patients nor the state budget can provide enough money to cover the whole cost of inpatient and outpatient drugs. The low official personal income levels and the fact that a large part of the economy (and individual incomes) is unofficial makes it difficult to increase contributions based on salaries. The available funds cannot match the increasing demands of the population, even if funds from regional and municipal levels are taken into account.
At present the Ministry of Health can only allocate 1–2 Lari per capita for outpatient health care, including drugs, provided the state programmes run in parallel. In this low budget situation a drug reimbursement system can only provide some relief in priority areas.
3.2 Objectives
Against this background, plans are being developed for the introduction after 2000 of a health insurance system. The Ministry of Health is seeking to develop a drug reimbursement system that is: · socially fair and covered large groups of the population · relatively easy to implement and administer in the current situation · allowed the possibility of eventually including state programmes and/or hospital drugs · possibly operable in a future health insurance system.
Given the lack of funds to finance a comprehensive drug reimbursement system, the Ministry of Health has to set priorities. A drug reimbursement system should be realistic and of real help to the population. Different variants of feasible and affordable drug reimbursement systems have been evaluated in a series of consultations between the relevant authorities in the health and pharmacy sector, the Ministry of Health and outside experts. This has resulted in a decision to develop a mechanism to compensate patients for excessive drug costs, which could be covered by available funds and – as a matter of priority –provide some relief for the worst-off patients.
3.3 Design of the system
Assumptions The drug reimbursement system chosen compensates people with high annual costs of drug treatment. This is based on the evidence that in any country there are many people with low drug costs and only a few people with high drug expenditure (Fig. 2). It is estimated that 20–30% of the population do not need any prescription drugs on an annual basis, 50–60% spend about the average per capita on drugs annually, and only some 15% spend far above average on prescription drugs annually. The latter thus spend an enormous amount of money on drugs.
EUR/QCPH 08 32 03 page 4
Total annual Total annual drug cost cost Reimbursed
Annual cost for the patient Baseline Patient payment
Time
Fig. 2. Approximate drug expenditure per capita
The pilot system focuses on the heavy users. It works by reimbursing that part of a patient’s drug expenditure over a certain annual amount (baseline), regardless of the patient’s personal income. The baseline, initially set at 100 Lari per patient per year, may later be lowered or raised depending on the funds available. The compensation percentage (initially set at 50%) above the baseline may also be lowered or raised. Different baselines and compensation levels may be introduced for different kinds of patient: this would of course require more complex methods of identification and administration.
Benefits Patients, who are members of the scheme, pay 100% of their drug costs up to the baseline. If their costs rise above this point, 50% of the additional cost will be reimbursed to them. The other 50% will be billed by pharmacies to the reimbursement authorities. Reimbursement is based on registration of drug purchases in a booklet for each patient. The scheme thus provides only partial compensation for drug expenditure above the baseline for items on the essential drug, or reimbursement, list (the positive list) on prescription (Annex 9).
The decision to give compensation for only a proportion of drug expenditure above the baseline needs some explanation. Complete reimbursement above the baseline is a more social approach but has some disadvantages, for example: more drugs will be bought once the baseline is passed, patients will do everything they can to pass the baseline, and abuse of the system is easy (patients who have passed the baseline may buy drugs for others, doctors may be invited to make excessive prescriptions). Keeping the patient co-payment (for example, a certain percentage of the drug cost or a fixed fee) above the baseline is less helpful for the poor but does not have the disadvantages of complete reimbursement. But although partial reimbursement creates a heavier administrative burden and complete reimbursement would be easier to administer, it was felt that a partial reimbursement system would be more feasible in the current situation (Table 2).
Table 2. Summary of coverage of reimbursement system
Reimbursement covers Reimbursement does not cover:
· all patients on a voluntary basis · drugs not included in the list · outpatient care · purchases at unlicensed pharmacies and kiosks
EUR/QCPH 08 32 03 page 5
· all prescription drugs on a reimbursement list, based on · over the counter drugs the national essential drugs list · purchases at licensed pharmacies. · purchases without prescription. Similar systems are or have been operating in some northern European countries. However, in northern Europe the systems are aimed at limiting government contributions and increasing patients’ payments, whereas in Georgia the system aims at limiting (excessive) payments by patients.
Membership Membership of the pilot system started on a voluntary basis. Discussions with national and local authorities about an obligatory system with complete coverage of the entire population did not result in a feasible solution, firstly because no budget funds were available to ensure wide participation, secondly the population had little trust in state-run systems, and thirdly there was no legal basis for such a compulsory system. The voluntary character of the pilot system meant that there were additional requirements in its design, implementation, promotion and introduction.
There were long discussions about the price of the booklet, or membership fee. This had to take into account: · the benefits of the system (to ensure the system’s liquidity) · the average monthly income (both official and unofficial) to make it affordable · other payments (official and unofficial) for health care · the attractiveness of becoming a member of the system.
The price was eventually fixed at 3–4 Lari per booklet (depending on the family’s situation), but after one month an average price of 2 Lari appeared to be more appropriate.
The Drug Polis reimbursement system is a voluntary drug insurance system, under which people are not charged a premium payment related to their salary but a fixed participation fee (the price of the booklet), regardless of their income.
Additional considerations – refining the pilot system The basic features of the system were subsequently refined to take into account patients’ behaviour and general health-seeking behaviour, to make the system as attractive as possible for voluntary participation, and to keep it manageable and controllable.
Patients’ behaviour and general health-seeking behaviour · People tend to buy prescription drugs without consulting a doctor and therefore without a prescription, as fees for visiting a doctor add to the cost of treatment, especially as they have to pay out-of-pocket for visiting a doctor or polyclinic for many diseases. The polyclinics were therefore involved to get them to offer discounts on doctors’ fees. This issue remained a problem, as the benefits of the system hardly outweigh the extra expenditure on doctors’ fees (see sections 5 and 6 below). · Prescription forms were no longer in use. This was solved by reintroducing prescription forms, which in fact became part of an effort to reintroduce them nationally.
EUR/QCPH 08 32 03 page 6
· The essential drugs list was not widely used when the pilot project started, so a list of drugs for reimbursement (positive list) was drawn up based on the generic names of essential drugs plus some other frequently used drugs. This list, including both brand and generic names, was made available in pharmacies and polyclinics. · Some frequently used drugs are not on the essential drug list. To make the system attractive some of these were included in the reimbursement list. · Some of the drugs that should be provided through state programmes are not always available meaning that patients have to buy them in pharmacies, which adds to their drug expenditure. They were therefore included in the pilot project, on the assumption that if they were available within state programmes patients would prefer that option. · Chronic patients needed a prescription for every claim in the booklet. This problem was solved by issuing them with a standing numbered prescription for one year which they had to show together with their Drug Polis booklet in the pharmacy.
Attractiveness to the public The following measures appeared to make the system more attractive: · adding further benefits for patients before they reached the 100 Lari baseline: the pharmacies agreed to give a 10% discount on all prescription drugs for booklet-holders, and the fee for visiting a doctor was reduced; · inclusion of children on the booklet of the mother: expenditure on prescription drugs for children aged 3–16 years can be noted in mothers’ booklets, helping them to reach the 100 Lari limit more quickly after which both mother and children were entitled to 50% reimbursement; · adding some frequently used drugs even though they were not on the essential drug list.
Other ideas eventually did not work out as anticipated. For example, the membership fee initially depended on the number of family members joining the system: the more family members, the lower the fee per person. This, however, appeared to be too complicated and the idea was dropped after the first months.
Attractiveness for pharmacies The system also had to be attractive for pharmacies. Here a number of problems needed to be solved. · Pharmacists mistrusted the speed of payment in any system for historical reasons. The reimbursement system would pay the pharmacists within one month after receiving an invoice. Guarantees for swift payment were given by assurances received from WHO and by making available a buffer budget in a local bank. · Pharmacies only wanted to join the system if they would be part of a limited group, for marketing and competitive reasons. This coincided with the idea of initially limiting the number of participating pharmacies for reasons of control and monitoring. The project started with five pharmacies in different parts of the city, selected on the basis of the quality of the pharmacy and its staff (inspection), its geographical situation and monthly sales. · Attitudes of the participating (as well as other) pharmacies towards the pilot initiative were mixed. Some trust needed to be developed as well as promotional and genuine good pharmacy practice (GPP) skills. Special seminars were held to take care of this and GPP training was provided in Denmark.
EUR/QCPH 08 32 03 page 7
· Pharmacies were heavily involved in promoting the system, which gave them high visibility in local political spheres as well as in the local community.
Control Every system that redistributes money runs the danger of the participants cheating in an effort to get additional benefits. Patients may try to collect prescriptions from different people on one card or try to convince doctors to cooperate with them. Pharmacies may write non-reimbursable items under reimbursed names or charge higher prices. The extent of this danger was hard to assess; one of the aims of running a pilot project in a limited population was to get some information on this issue.
The system has certain features that discourage these practices. One such is the 50% patient’s payment above the baseline, which ensures that patients remain cost-conscious. Then there is the wide availability of price and product information, meaning that patients, pharmacies and the reimbursement fund can verify the prices. There is also very detailed information on the patient’s card which has to be verified by the doctor, pharmacy, patient him/herself and the fund.
Control of patients, doctors and pharmacies is primarily exercised through preventive measures. Direct control is exercised through sampling and in extreme cases or complaints. If a patient, doctor or pharmacy is found to be misusing the system, they are immediately expelled from participation and fined.
Information Information and communication are targeted at different users, influences and other stakeholders. 1. The general public was informed by the mass media (newspapers, local television and radio stations) and by outdoor advertising. The Kutaisi municipal offices and the contracted pharmacies and polyclinics also played a significant role in informing the population about the system and its benefits. 2. Patients were able to get additional details of the system in the municipal offices and in pharmacies. 3. Pharmacies were involved in the development of the system from the outset. They were given detailed instructions about the administration of the system and briefed in several seminars. Their role in providing information to the public was again emphasized during training in good pharmacy practice in Denmark. 4. Doctors were made aware of the rules of the new reimbursement system in seminars and through written instructions sent to the polyclinic. The latter included the positive or essential drugs list, reimbursement rules, and the use of prescription forms. Some additional information and training on proper drug selection was added.
3.4 Final concept of the pilot system
Taking into account all the requirements described in paragraph 3.3 and certain adjustments made in the first 2–3 months, the benefits in the pilot system finally looked as indicated in Fig. 3.
The benefits of the pilot system, the membership conditions and some other features are summarized in Box 1.
EUR/QCPH 08 32 03 page 8
During the first year, several trials were made to improve the system’s attractiveness or to catch the attention of the general public (section 5).
Fig. 3. Benefits available in the Drug Polis reimbursement system
Pharmacy discount 10% Drug Polis reimbursement 50%
90% Patient payment 50%
0 Lari 100 Lari more
Expenditure on prescription drugs per year
Box 1. Key features of the Drug Polis reimbursement system
I. Membership: i) Voluntary for all citizens of Kutaisi. ii) Price per booklet: 2 Lari per person for one year’s membership; price is adjusted per quarter. iii) Children aged 2–16 years have free membership when the mother is a member. iv) Special offers: · reduced membership fee after the Christmas period · free trial period of one month at Easter. II. Benefits: i) Below the 100 Lari limit on expenditure on prescription drugs: · discount of 10% on all prescription drugs (including drugs not on the list) in the participating pharmacies; · prescription not obligatory but recommended; · fee for visiting a doctor in the participating polyclinics reduced by 20%; · entitlement to special offers from Drug Polis or participating pharmacies. ii) Above the 100 Lari limit registered in the booklet: · reimbursement of 50% of all expenditure on prescription drugs from a positive list on showing an official prescription form filled out and signed by a certified doctor; · entitlement to a 10% discount on prescription drugs not on the positive list or not supported by a prescription form; · 20% discount on visits to doctors in participating polyclinics; · entitlement to special offers from Drug Polis or participating pharmacies. III. Other: i) Booklets can be obtained in municipal offices and (later) in participating pharmacies. ii) Chronic patients only need one prescription, valid for one year.
4. Implementation
4.1 Starting up
The process from concept to implementation can be characterized as a continuing review of all elements of the proposed system at every stage. Even after the system had been introduced, several changes were made to tailor it better to daily life in Kutaisi. The main issues were: · repeated efforts to overcome an apparent lack of trust (in any new system); · adjustment of concepts and details to make them more attractive to potential clients;
EUR/QCPH 08 32 03 page 9
· improvement of the drug list (more drugs); · better prices and an easier to communicate price differentiation for the booklets; · acceptance that for the time being, Drug Polis can only be offered to individuals and not in the form of collective packages to employers, whether public or private; contributions from the budget for vulnerable groups are foreseen later (in 1–2 years); · involvement of pharmacies and polyclinics and efforts to get them to commit themselves to being stimulating participants in Drug Polis; · sales of booklets that did not deliver a large and immediate financial gain; · problems with taxation on the 10% discount offered by pharmacies.
These adjustments and the learning curve experienced by WHO and the local project team were valuable and useful for further development of this and similar reimbursement systems.
4.2 Organization
The organization of the pilot reimbursement system was entrusted to the non-profit foundation “Tanadgoma”, established especially for this purpose with the support of the municipality (Fig. 4). Drug Polis is the first and major activity of this foundation.
Fig. 4. Organization of the Drug Polis pilot drug reimbursement scheme
Emereti Region Initiators Ministry of Health Parliament of Georgia World Health • Minister, Deputy Minister • Committee for medical and • Governor Organization • Pharmacy Department social affairs • Fiance Department • Health Department
Contract partners Kutaisi City administration Citizens of Kutaisi
Advice Tanadgoma Foundation Financial support Assistance Organization DRUG POLIS
Collaborators Municipalities Polyclinics Pharmacies
The management of Drug Polis consists of one project manager, one assistant project manager and one administration/informatics assistant.
Local support was provided by the head of Imereti Region Finance Department and the pharmaceutical inspector. In addition a steering group was formed with representatives from the Ministry of Health, the Parliamentary Committee for Medical and Social Affairs and the city administration. WHO provided technical and financial support through the Special Project on Pharmaceuticals for the Newly Independent States, a collaborative arrangement between the WHO Action Programme on Essential Drugs and WHO Regional Office for Europe Pharmaceuticals Programme.
EUR/QCPH 08 32 03 page 10
Positive comments and support were received from UNICEF and the World Bank as regards the concept and the possibility of a future health financing system.
4.3 Administration
The administration of the pilot project was carried out according to: · administrative guidelines for pharmacies (Annex 1) · guidelines on selling booklets (Annex 2) · administrative rules for using the booklets (in the booklet, Annex 3).
These guidelines and rules were developed by the WHO Special Project for the Newly Independent States in close collaboration with the local project team. In the course of implementing the pilot project, these administrative rules underwent some changes, although their basic intention and modus operandi remained largely unchanged.
The project office was equipped with a computer, fax and e-mail connections for administering membership and claims and to facilitate direct contact with WHO and the Ministry of Health.
The financial transactions were carried out independently by the project office through normal bank-to-bank transfers.
4.4 Information system
The administration of the booklet sales, membership data and reimbursement data (claim management) were done with a computer database (see Annex 8). The information stored in this database is the following: · booklet number; · name; · address; · fee paid; · number of children; · date of entry; · limit for reimbursement in Lari (depending on date of entry); · percentage reimbursement (the same for everybody at this stage, but could be different for certain groups); · point of sale of booklet; · drug consumption (before and after limit), by type and quantity.
4.5 Communication and promotion
The introduction and development of the voluntary pilot scheme required extensive efforts as regards information and communication. The kind of information, target groups and means and forms of communication were set out and discussed in a comprehensive communication plan (summary in Annex 5). The forms of communication consisted of: · the booklet · large posters · small posters · leaflets and handouts
EUR/QCPH 08 32 03 page 11
· press summaries · television commercials · short television messages. In the course of implementing the scheme, several deviations from the initial communication and information plan had to be made. This was mainly because it was initially difficult to convince people, and especially to gain their trust after they had seen so many initiatives and promises with no tangible results. Secondly, certain means of communication appeared to be less effective and others more effective and plans had to be changed accordingly. Thirdly, more promotion efforts were made than intended, as the public appeared sensitive to action-oriented promotion.
4.6 Political and local support
The project has enjoyed substantial local and regional support. When the local authorities were informed and lobbied and the intentions, objectives and implementation of the project discussed with them, they became committed and involved. This commitment contributed to inspiring and stimulating the local staff and was encouraging at difficult moments. It also helped to overcome certain barriers and setbacks and was thus essential to the project.
5. Results
5.1 Membership development
Autumn 1997 The project started in October 1997 with a major information and communication campaign, with the pressure increasing towards Christmas and several promotional activities being carried out in the New Year period. The take-up of new members in that period was very unsatisfactory, the main reasons being: · lack of trust – people did not believe that the scheme was meant to help them and not just a way of getting money out of them; · the 3-4 Lari fee for the booklet was too high; · the communication messages were perceived as too complicated.
Winter 1998 In the winter the number of new members increased slowly, partly following a reduction in the membership fee (presented as an additional contribution from WHO). Several people bought the booklets when they fell ill: the benefits become more visible and tangible at such moments.
Spring 1998 There was a real increase in the number of participants around Easter as a result of renewed heavy promotional efforts and the possibility of a free trial month. After this trial month people were free to return the booklets to one of the participating pharmacies or pay the membership fee to date.
Summer and early autumn 1998 Thanks to the success of the promotional activities in the spring, word spreading through the people who had joined and a somewhat more active approach by the participating pharmacies,
EUR/QCPH 08 32 03 page 12
new members continued to join. By October no new members were accepted in view of the short remaining validity period of the booklets.
Total membership take-up Fig. 5 shows the monthly uptake of members and the cumulative number of participants. The major influx was in April–June, coinciding with changes in the promotion campaign to build on the heavy promotion since autumn 1997 and financial incentives such as the free trial period. By the end of 1998, 12 000 booklets had been sold, 7500 of them in the period April–June.
Fig. 5. Total membership take-up in the pilot project
Monthly Cummulative uptake member count 6,000 12,000
5,000 10,000
4,000 8,000
3,000 6,000
2,000 4,000
1,000 2,000
- - Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- 97 97 97 98 98 98 98 98 98 98 98 98
Composition of the membership Data on age were collected through the registration of members when the booklets were issued. The majority of the members were aged over 50 years, one third were between 30 and 50 years. The average income was around 40 Lari per month and members were either not employed (elderly) or had one employed adult in the family.
Table 3. Composition of membership of Drug Polis
Membership: total number 12 000 By age group: under 30 years 12% 30–50 years 34% over 50 years 54% By employment: 2 employed adults 15% 1 employed adult 42% no employed adults 43% Average income 42 Lari per month
Source: Membership database of Drug Polis; survey results.
EUR/QCPH 08 32 03 page 13
5.2 Financial results
The financial results of the first Drug Polis year are split into: a reimbursement balance (actual compensation by the system after members have passed the 100 Lari limit or the equivalent if they joined later), an investment or development overview, and an overview of the benefits for patients including a 10% discount on purchases before they reach the 100 Lari limit or equivalent (Table 4).
Table 4. Financial results of pilot project (in Lari)
Category Income Expenditure Reimbursement balance Membership fees 5 400 Reimbursed (50% compensation) 4 000 Positive reimbursement balance 1 400 Total 5 400 5 400 Development balance WHO grant 8 680 Advertising and promotion 4 000 Administration 3 000 Booklets 1 680 Total 8 680 8 680 Benefits 10% discount in pharmacies 15 000 50% compensation (>100 Lari) 4 000 Total benefits 19 000 Total benefits per active member 3.17 Cost per active member 2.00 Net profit per active member 1.17 Net profit/Cost 58%
Reimbursement cost The reimbursement balance shows a positive balance (1400 Lari) due to the fact that only a few people exceeded the 100 Lari limit. The total compensation (50%) for these members totalled 4000 Lari. Total membership fees received was 5400 Lari. These results led to the following conclusions: 1. The limit of 100 Lari is probably too high. 2. The fact that most members joined late, in April–June, may have influenced the way the system was used and prevented some patients from reaching the 100 Lari limit.
Development cost The total start-up costs – administration, promotion and printing of the booklets – came to 8680 Lari. These were covered by the WHO Special Project on Pharmaceuticals in the Newly Independent States. The Pharmaceuticals Department of the Ministry of Health took care of printing and disseminating prescription forms to polyclinics.
Draft materials and an information system were designed and developed by WHO. The cost of these is not included in the financial overview.
EUR/QCPH 08 32 03 page 14
Benefits Benefits for participating patients consist of the 50% compensation for drug expenditure over 100 Lari and the 10% discount given by pharmacies below the 100 Lari limit. This came to 19 000 Lari. Since approximately 50% of the members did not use their card (see section 6), this 19 000 Lari benefited 6000 members. In other words, there was a profit of 1.17 Lari per booklet that cost maximum 2 Lari (58% net return).
It is clear that the 10% discount provided by the pharmacies, a kind of early benefit, is a major contribution to the benefits and attractiveness of membership.
5.3 Other results
Apart from the direct financial benefits that members received, the project has delivered several other non-financial results.
Much important experience has been gained in the management of a drug reimbursement scheme in the current environment in Georgia. This can be passed on to other regions and other countries in transition. The main areas where lessons have been learned are: · marketing, promotion and sales of booklets · management of pharmacies (client orientation, patient communication) · involvement of polyclinics · financial management of a drug reimbursement scheme · local project management.
Information on the cost per patient, prescribing habits, the kind and quantities of hospital drugs bought in retail pharmacies, and other important drug utilisation data has been collected and can be used for further analysis.
An extensive social survey compared members of the scheme with non-members in their situation, knowledge, opinion and experience with Drug Polis (section 6).
Finally, the health care and pharmaceutical services and professionals have benefited from further WHO assistance by including their experience with the pilot scheme in related activities, such as: · retail pharmacy training for participating pharmacies: patient information and communication, pharmacy management, customer orientation, product presentation, good pharmacy practice (Denmark); · Workshop in rational prescribing for physicians and polyclinics; · Seminar on Treatment Guidelines and the Use of the Essential Drug List; · Seminar on Regulation and Management of the Pharmaceutical Sector.
6. User survey
A team led by Marine Chitashvili, Faculty of Psychology, Tbilisi State University, conducted the user survey. After an initial briefing and discussion of the draft questionnaire, the survey was held independently and the research results can be considered to be representative and unbiased.
EUR/QCPH 08 32 03 page 15
6.1 Methodology
The aim of the survey was to collect public reaction to the pilot drug reimbursement system. Both members and non-members of Drug Polis were surveyed for their awareness of the project, willingness to participate, and their wishes regarding its current shape and major obstacles to participation. The purposes of the survey were defined as follows: 1. to measure awareness of the system and what people know about it; 2. to investigate factors that play a role in deciding whether or not to participate; 3. to find out positive and negative aspects of its current shape, ways of communication and distribution channels.
The results of the survey should lead to improvements in the system, its current shape, communication aspects, and the sales of the booklets, in accordance with the public’s wishes. It should also provide better information about specific target groups.
The survey was conducted by structured face-to-face interviews with a selected sample of members and non-members of the scheme. The selection of members was based on the Drug Polis information system, while non-members were selected on a random basis (Table 5). Interviews were carried out with the following categories of people:
Table 5. Categories of people interviewed in the Drug Polis survey
Target group Polis members Non-members Profile
1. Mothers (20–40 years) 50 50 With children 2. Senior/elderly people (>55 years) 50 50 Without children 3. Others 50 50 Without children
The survey was designed in a way that will allow it to be easily repeated (or parts of it) at a later stage.
6.2 General opinion of members and non-members
The general opinion of the Drug Polis idea is quite positive. Some 62% of all those interviewed indicated that they would like to have such an insurance. A majority had heard about Drug Polis (67%) and wanted to receive (more) information (62%).
The public had come into contact with Drug Polis through a variety of communication and distribution channels – through colleagues/friends/family (25%), their municipality (25%), pharmacists (22%) or (television) advertising and promotion (16%).
After initial indications that there was very little trust in a new drug reimbursement system (illustrated by the slow take-up of members in the first six months), the question as to whether people trusted Drug Polis was crucial. The response was: yes – 53%, no – 47%.
EUR/QCPH 08 32 03 page 16
Although no similar question was asked before the pilot project started, we consider the fact that a small majority trusts the system an important positive effect.
When asked about possible improvements, a large group indicated that they would like to see lower drug prices (44%), while 20% wanted better information. Some insist on free medicine (12%), while others want more drugs on the reimbursement list (7%). A minority (7%) would like to see membership made easier.
Individual spending on medicines was also measured to get an indication of the relevance of the 100 Lari limit (Table 6). From the responses it is clear that approximately 30% of the population would reach the 100 Lari limit in the course of a calendar year.
Table 6. Drug expenditure per month
Amount Share (%)
0–5 Lari 51 6–10 Lari 19 11–15 Lari 7 16–20 Lari 7 21–30 Lari 6 31–50 Lari 5 51–100 Lari 2 100 Lari and over 2
6.3 Membership
Membership is to a large extent financially motivated. Over 60% said that their main motive in joining was the discounts available and the calculation of the benefits these would bring.
Other arguments to join were advice by others (23%), indicating that there was an element of social promotion through word of mouth. Quite a lot of members (20–35%, depending on population group) also advised others in their circle to join.
An important outcome of the survey is the degree to which the booklets were used. Approximately half the members did not use their booklets, possibly because booklets were given out for a free trial period or in connection with promotional activities for people belonging to specific target groups. One third of the members used their booklets five times or less, which did not really allow them to enjoy the benefits. Only 12% of the members interviewed had used their booklets frequently.
Members were also asked to comment on their experience with Drug Polis. The main remarks were: · the cost of obtaining a prescription: to see a doctor costs money and makes the benefits less attractive (this point was foreseen and a 20% discount on polyclinic fees for members was negotiated, but these costs are indeed an extra burden); · better and more comprehensive information should be made available to members;
EUR/QCPH 08 32 03 page 17
· a majority of the members considered the benefits good for themselves or their children, one third of the members considered them inadequate, while 19% said they did not need them; · discounts and benefits in the pharmacies were clearly the main motives for joining, as well as certain individuals’ high monthly cost of medicines; other reasons, such as privileges in polyclinics, are minor considerations; · service, collaboration and information in pharmacies apparently need improvement.
6.4 Conclusions – the public view
The main conclusions of the survey are as follows. 1. Over 60% of the people interviewed want to join Drug Polis. 2. Over 50% of the people interviewed expressed trust in the reimbursement scheme. Initially this posed a major obstacle. 3. Financial considerations are the main reasons for people to join the scheme. There seems to be room for different options whereby people could pay a higher fee and receive more benefits. 4. People heard about Drug Polis through different channels of distribution and communication. The promotion campaign certainly did a big job, but it is clear that a greater variety of forms and media should be used for communication. A useful suggestion was to work with agents. 5. Insufficient information is a serious weakness. This is partly the result of changes made during the early stages and the wish to get as many members as possible. The provision of information to members and through pharmacies should be improved. 6. The price of the booklet in combination with other co-payments is a matter of concern. It is still difficult for people to spend money on insurance services. Many take the burden as it comes and do very little to prevent it. 7. It appears that Drug Polis has attracted middle income groups. The price of 2 Lari for the booklet is too high for vulnerable and poor people, who can only become members if someone else (the government or sponsors) will fund their contribution. 8. The pharmacies could be more pro-active and play a bigger role in the sale of booklets, information exchange and point-of-sale advertising. 9. The 100 Lari limit for reimbursement is too high and should be lowered (in real terms).
The survey delivered valuable conclusions and suggestions, several of which will lead to changes in the concept, organization and communication aspect of the pilot project’s second year.
7. Conclusions and recommendations for further development
7.1 Conclusions
In summary the main conclusions are the following. 1. The pilot project has shown that there is a demand for a comprehensive drug reimbursement system. 2. A drug reimbursement system where benefits increase with growing drug expenditure can be financially feasible and managed in Georgia (and possibly in other transition economies).
EUR/QCPH 08 32 03 page 18
3. This system appeals to two thirds of the population. 4. The sustainability of any drug reimbursement system on a voluntary and independent basis is doubtful since voluntary premium payments are a major obstacle for a large part of the population, due to financial constraints and mind set. The state should take care of this. 5. A similar system of risk pooling might, however, be viable and sustainable when incorporated in a comprehensive compulsory health insurance scheme, where there are no separate premium payments, or in combination with PHC services and offering a more comprehensive service and benefit package. 6. The concept of a fixed premium or fee per insured person, independent of income, and possibly with discounts for family dependents, has worked well and been appreciated by the public. Given the substantial grey income and unreliability of income data, this fixed premium concept could be used in other areas of health insurance in combination with provisions or subsidies for identified vulnerable groups.
The main objectives of the pilot drug reimbursement scheme were that it: · should be socially fair and cover large groups of the population · should be relatively easy to implement and administer in the current situation · allowed the possibility of eventually including state programmes and/or hospital drugs · should possibly be operable in a future health insurance system.
Have these main objectives of the pilot reimbursement system been achieved? The answer is yes.
The system is fair – compensation depends solely on the level of drug expenditure. It is relatively easy to implement and administer – its management does not require a lot of staff, provided computer support is available. It is possible to include drugs provided under state programmes – a percentage reimbursement or their free dispensation is possible on presentation of the booklet. Hospital drugs might be included in the drug reimbursement list, although to do so would substantially increase the cost and is therefore not advised. The system can easily be operated in a comprehensive health insurance scheme, provided membership identification is possible.
7.2 Lessons learnt
In addition to the foregoing conclusions, the pilot project provided several other lessons for the future. 1. Systems designed and functioning for middle income groups can, with specific adjustments, benefit poorer groups. However, even when the benefits are provided free, the participation of the lowest income groups remains low, due to mistrust and the psychological barrier of running the risk of being charged or victimised. Additional efforts are needed to make these groups participate and benefit. Their participation needs to be financed by either (local) authorities or external donors. 2. Voluntary systems should offer substantial benefits immediately. 3. Communication with the public should contain only one message, be clear and relatively simple. 4. Drug reimbursement schemes cannot be based on an essential drug list alone. They should also contain items that are frequently used (sometimes as substitutes for the items on the list)
EUR/QCPH 08 32 03 page 19
to ensure that the benefits are attractive. The inclusion of such drugs needs to be based on local circumstances and common sense. 5. The system sometimes functioned as a safety net for drugs that should be provided free under state programmes. When these free drugs were not available, patients bought them in pharmacies, where they were included in the reimbursement scheme. 6. Participation of pharmacies should be limited to those that carry a wide range of products, have a patient-oriented attitude (willing and able to explain about reimbursement and use of the booklets) and are economically sound. Good management is crucial if pharmacies are to be successful partners in drug reimbursement schemes. 7. A voluntary system, and probably also a compulsory system, may benefit a lot from agents who are able to explain how it works, answer the public’s questions, be used for distribution purposes and have an ambassador function (promotion). These agents can be pharmacies, polyclinics and staff in municipal offices or independent people. 8. The current system did not show evidence of any major abuse or fraud because of the limited number of pharmacies and of the fact that a co-payment is always required. If booklets are given free to some groups or reimbursement levels are close to 100%, misuse of the system will probably increase. 9. The design, development and implementation of drug reimbursement systems requires (i) high level political support, (ii) involvement and commitment of local (health) authorities, (iii) a strong sense of the immediate incentives for all participants, and (iv) an in- depth analysis of health-seeking behaviour and the financial incentives for premium payers and patients. 10. In the first year, Drug Polis aimed to attract individuals to membership. This required a huge promotional effort and delivered modest numbers of new members: the increased take-up was related to increased promotional efforts. Attracting groups of people will demand different promotion techniques (networking, lobbying) and probably deliver a higher number of new members. The danger of negative selection will also be diminished. 11. Information about a drug reimbursement system is by its nature rather complex. Despite this, efforts should be made to make the information easily understandable and widely available, as well as being consistent over time. 12. The pilot system collected good data on drug consumption in Kutaisi that can be used in rational drug use programmes. 13. The cost of a visit to the doctor is a major obstacle for participation in the pilot project, due to the accumulation of official fees and possible additional payments. 14. The inadequate link between primary care physicians and the drug reimbursement system results in a lack of incentives for doctors to prescribe more rationally on the basis of the reimbursement list. This is weakening both concepts. 15. The cost of drugs together with the cost of primary care are providing the wrong incentives to patients (lowering access) and pushing patients into free hospital care. To discourage the use of secondary care, access to primary care should be free. Reimbursement of outpatient drugs is a necessary condition for this. Already the risk of having to pay a limited amount of money stops people seeking care. Therefore a combination of primary care and drug reimbursement or an outpatient drug reimbursement scheme incorporated into a wider health insurance scheme will provide better incentives for patients to seek adequate care. In
EUR/QCPH 08 32 03 page 20
addition, a proper referral system is needed to prevent direct access to secondary care, which now competes directly with primary care.
7.3 Recommendations
The following recommendations are made on the basis of the conclusions and results of the first year of the pilot project, and with the ultimate objective of preparing a drug reimbursement system that can be operated in a comprehensive health insurance scheme. 1. The Drug Polis should be continued in Kutaisi and extended to the Imereti Region, and the changes proposed in the survey report and this first annual report implemented. 2. Other pilot sites should be sought, preferably in combination with the Georgian health insurance fund or with an integrated primary health care project. This is to assess the feasibility of the drug reimbursement concept in combination with these services, with the aim of diminishing the financial barrier for the public. 3. The financial and other parameters of a draft drug reimbursement scheme at national level should be extrapolated. This could be finalized after the results of 1 and 2 above become available.
Annex I Distribution of drug costs as a basis for risk pooling parameters
1. Preliminary remarks These sales estimates and derived market size results Estimating the budget needs for a reimbursement in a market (ex. hospital drugs) of 36.8 million Lari. system, when almost no information is available is For 1997 a market size of 60 million Lari (at mid- nearly impossible. Still, some estimation has to be 1996 prices) is foreseen (growth of 65%). done, even if it is not very accurate and based on very Calculations will be based on a market value of 60 rough and simple data. million Lari for 1997. In order to make this rough estimate, the following The share of essential drugs in the total market varies information was used: from 25 to 35%.
· estimation of the total market value of Drug expenditure pharmaceuticals based on monthly sales figures from pharmacies in Tbilisi and several selected The distribution of the total cost of medication over regions (monthly survey performed by the the population is not known. However, there is data Ministry of Health). These figures were available from some western countries, including the compared with import/export data from the share in the total expenditure on insured medicine of customs department. each user group. These (1995) figures are presented in the following table: · estimation of the share of essential drugs in the total drug sales, also from the monthly pharmacy survey. Distribution of accumulated cost of medicine in selected western countries (% of insured in 1995) · estimation of the distribution of the accumulated Sweden Netherlands Finland Average cost of drugs over a population. This estimation zero 38% 24% 25% 29% is based on relevant figures from Finland, up to 1/2 average 41% 44% 44% 43% Sweden and The Netherlands. Adjustments for 1/2 average to 2x average 12% 19% 21% 17% the Georgian situation were made based on 2x average to 5x average 5% 8% 6% 6% assumptions about drug purchasing behavior in more than 5x average 4% 5% 4% 4% Georgia with low income levels. 100% 100% 100% 100% · Estimation of the share of the so-called heavy users in the total expenditure of pharmaceuticals. In the presented countries only 4% to 5% of the It has to be said that the estimate derived from these insured have an annual drug expenditure of 5 times or data is obviously not very accurate. Verification of higher than the average expenditure per insured these data and parameters is needed in a pilot or test person. But these people (heavy users) account for project to verify the assumptions and recalculate the app. 35% to 45% of the total cost for the budget needs accordingly. reimbursement system. Detailed information about these heavy users from The Netherlands learns the following: 2. Assumptions · 5 - 10 times average 3,5% of insured 23.5% of the total cost · over 10 times average 1,5% of insured 22% of Market size the total cost The sales per pharmacy are measured by the survey Figures from other countries indicate the same from the Department of Pharmacy. Based on the distribution of insured versus cost. number of outlets in the country a market size in Lari (prices mid 1996) is calculated: The Georgian situation is of course different. The consumption of medicine (in volume per capita) was originally higher (inherited habits from the former Market size pharmaceuticals at pharmacy prices (mid ’96) Soviet system), but today the lack of money (both at patient and government level) limits the purchase of Pharmacy Turnover per outlet Market drugs. This leads to the following assumption: Outlets (nr) per month per year 1996 - In Georgia, compared to western countries, there Pharmacies urban 300 2,047 24,559 7,367,760 will be less people with no drug expenditure Pharmacies rural 700 1,535 18,419 12,893,580 (category zero) and the accumulated expenditure Kiosks 1,800 767 9,210 16,577,460 will be lower for high spending persons (due to a Total 36,838,800
WHO Special Project for NIS 1 lack of money). There will be a larger number of 100 Lari earlier and the number of card holders people in the higher spending categories. claiming 50% reimbursement will increase. This is of course a social benefit for families with young The distribution of the annual drug cost per patient children, but fair considering the cost of medication derived from this assumption for Georgia then looks for mother and child care. as follows: Limiting reimbursement to essential drugs has So, app. 7% of the patients have an annual drug probably only a limited effect on the claims of heavy Distribution of accumulated cost of medicine in users. This, because people who are seriously ill will Georgia (% of patients in 1995) mostly require essential drugs. So the majority of Average SWE, estimate Georgia their total expenditure already consists of essential FIN, NET drugs. zero 29% 15% up to 1/2 average 43% 45% Conclusion 1/2 average to 2x average 17% 25% 2x average to 5x average 6% 8% Neither the cost decreasing effect nor the claim more than 5x average 4% 7% increasing effect can be measured exactly. Only a 100% 100% pilot or test phase where adequate information is collected and analyzed may provide the necessary expenditure of over 5 times the average. Based on a answers. For the time being it is assumed that both market estimation of 60 million Lari (’97) the effects will compensate each other to a large extend. average expenditure per patient is 13.3 Lari per year. This leads to the following assumptions: The 100 Lari baseline is then 7 times higher than the average. Approximately 5% of the patients will Market value 1997 60 million Lari exceed that baseline. The share in the total drug Heavy user patients 5% of the patients Share in total expenditure 40% expenditure of these patients will be app. 40%. Card potential 2/3 of the population (children on the mothers Claim decreasing elements card) Card participation 30-50% of potential A number of people already receive so-called ‘free Fee for the card 2.00 Lari drugs’ or some other kind of reimbursement through Various cost per card 1.50 Lari state programmes. These state funds are either directly given for the procurement of drugs or given to health care facilities to cover drug costs, or passed 3. Budget calculation for Georgia to municipalities who dedicate the funds to different target groups. In the table on the next page the budget is calculated Groups currently benefiting from these funds are according to the above mentioned assumptions. Three vulnerable people (extreme poor - 100.000), people variants are presented for Georgia nationwide. The with certain chronic diseases and diabetics (also most likely situation is shown in the gray colored estimated at 100.000), children under 1 year of age, area. Adjacent variants are calculated. Option-1 orphans, refugees, war veterans, patients in need of under the assumption that the heavy users have a oncology or life saving care (both hospital and higher share in the cost. Option-2 assumes that there ambulatory / polyclinic) and for treatment of is a higher percentage heavy users (7% instead of infectious diseases. 5%). The potential share of these benefits in the total drug expenditure is hard to estimate. But these benefits 4. Conclusion contribute to a lower cost of medicine to be paid by the patient than calculated above. As shown in the gray areas in the table above, the budget required is estimated at 6.8 million Lari if the Lower real claims to the reimbursement system may patient cards are not charged for. This budget also occur due to a lower patient participation in the decreases to an estimate of 3.8 million Lari when a scheme (too much effort, forget card, etc.), leading to small fee of 2 Lari is asked for every patient card less claims from the heavy user group issued. A wide participation of the population in the card system increases revenues and, by that, Claim increasing elements decreases the necessary budget. On the other hand, when issuing the cards to persons over 16 years of age and placing the children under WHO, Autumn 1997 that age on the card of the mother, the expenditure on the card of these mothers will reach the baseline of
WHO Special Project for NIS 2 Calculation of reimbursement cost and budget needs
National System Adjacent variants Georgia Option 1 Option 2
Population nr. 4,500,000 4,500,000 4,500,000 Potential nr. of cards to be issued (2/3) 3,000,000 3,000,000 3,000,000 Share > 7x average 5.00% 5.00% 7.00% Heavy users nr. 150,000 150,000 210,000
Total cost Lari 60,000,000 60,000,000 60,000,000 Heavy users share in total cost 40.0% 50.0% 40.0% Cost of heavy users Lari 24,000,000 30,000,000 24,000,000 Cost per heavy user Lari 160 200 114
Cards Participation 50% Various cost per card (incl. cards) 1.50 Total various cost Lari 2,250,000 2,250,000 2,250,000
Budget needs for heavy user groups Without card charge Patient contribution up to baseline 100 15,000,000 15,000,000 21,000,000 Copayment above baseline 50% 4,500,000 7,500,000 1,500,000 Patient contributions total Lari 19,500,000 22,500,000 22,500,000 Reimbursement payments Lari 4,500,000 7,500,000 1,500,000 Budget needs incl. other cost Lari 6,750,000 9,750,000 3,750,000
With card charge 50% Participation Card revenues 2.00 3,000,000 3,000,000 3,000,000 Budget needs incl. other cost Lari 3,750,000 6,750,000 750,000
Budget need relative to card participation (Lari) Card participation Georgia Option 1 Option 2 Without card charge 33% 5,985,000 8,985,000 2,985,000 50% 6,750,000 9,750,000 3,750,000 67% 7,515,000 10,515,000 4,515,000 Obligatory 100% 9,000,000 12,000,000 6,000,000
With card charge 33% 4,005,000 7,005,000 1,005,000 (2 lari per card) 50% 3,750,000 6,750,000 750,000 67% 3,495,000 6,495,000 495,000 Obligatory 100% 3,000,000 6,000,000 0
WHO Special Project for NIS 3 ANNEX II ADMINISTRATIVE GUIDELINES
3.3 If available donated drugs may be included in the 1. General conditions for the Reimbursement List with different patient payment administration the levels. reimbursement system 3.4 Changes in the Reimbursement List are announced in the authorized pharmacies and in polyclinics. 1.1 Prescriptions are the basic documentation for reim- bursement. 1.2 Prescriptions, to which a reimbursement applicable 4. Flow of work in the pharmacy - (or a copy), are to be kept in the pharmacy for at least 2 years. dealing with the patient 1.3 The Ministry of Health has elaborated a new 4.1 The patient receives a prescription for a subsidized prescription form. It is expected that the new pre- drug. scription form will be put into effect on 1 July 1997. From that date on the new authorized prescription 4.2 The patient comes to the pharmacy. The assistant forms must be used in all cases where a prescription checks whether this drug is on the reimbursement drug is dispensed under the reimbursement system. list. If negative, the patient is informed that he/she has to pay the full amount. 1.4 Only authorized pharmacies are entitled to dispense under the reimbursement scheme. Branch pharma- If positive: cies and pharmacy shops are excluded from the 4.3 The assistant asks if the person in question has a reimbursement system. Booklet. If negative the pharmacy gives the patient a 1.5 To ensure proper account keeping of the reimburse- Booklet information package, in which a Booklet is ment system, the patients are supplied with a Reim- enclosed. bursement Booklet (further to be called Booklet). If positive: All pharmacies will also receive a first edition of the 4.4 The patient shows the Booklet and the prescription. Booklet from the Drug Polis. The pharmacy checks that the civil registration 1.6 In addition only authorized pharmacies are supplied number at the prescription and at the Booklet are the with a separate drug reimbursement administration same. form. Pharmacies can order new forms at the Drug 4.5 The full sales price for the reimbursed drug is added Polis as the need arises. to the Booklet. Furthermore the pharmacy’s stamp, the pharmacy assistant’s initials and the date of filling are added. Make sure that the date on the 2. Issuance of the Booklets Booklet, for security reasons, always corresponds to the date stamp on the prescription. 2.1 Booklets are issued by the Drug Polis to patients 4.6 Instead of manual application of the information a upon request of the patient (if voluntary). computer printed label containing all relevant 2.2 Booklets are not issued to children under the age of information can be used. 16 as drug expenses for these are to be added to one 4.7 If the patient has not exceeded the amount of 100 of their parents’ Booklets. It is assumed that the Lari, the patient has to pay the full price. child brings this Booklet or that the parent is pur- 4.8 If the patient has exceeded the total amount of 100 chasing the drug for the child, using his/her Booklet. Lari on the Booklet the patient is paying 50%. The (2.3 Booklets are not issued to pensioners who have a remaining 50% is written on the pharmacy card - to medicine card from the municipality, as these be claimed at the end of the month to the Drug already receive subsidized drugs.) Polis. 2.4 At the turn of the year new Booklets are issued, with 4.9 If the prescription shows that there are to be more a different color or different serial numbering than fillings on the same prescription, the pharmacy has the Booklet of the previous year. to take record (i.e. copy) of that prescription. The patient has to keep the prescription form for later use. 4.10 In case the patient has forgotten the Booklet, the 3. Drugs included patient pays full price or has to return to take his/her Booklet. 3.1 The drugs included in the reimbursement system are published on a so-called Reimbursement List. This 4.11 In case the patient has lost the Booklet a new card is list is made available at all pharmacies, doctors, issued. Previous medicine purchases are regarded as polyclinics and will be given together with the lost in relation to the Booklet system in case the Booklet to the patient. medicine purchase cannot be documented by the patient or the pharmacy by showing filled prescrip- 3.2 The Reimbursement List may also include maxi- tions. mum reimbursement price levels.
:+2 Special Project in NIS 1 4.12 If the patient, however, finds the lost Booklet, the patient can, if the 100 Lari minimum has not been 5. Transactions between Drug reached, contact the Drug Polis and have the Polis and pharmacies amounts added to the latest issued Booklet. Here after the Drug Polis has to take in the previously lost Pharmacies included in the reimbursement system are to Booklet so that the patient is only in possession of be authorized by a special permit or contract with Drug one card. Polis. Authorized pharmacies are complying to the 4.13 When the 100 Lari limit is reached the following following rules. model should be used: 5.1 The pharmacies have to follow all administrative The patient has bought for 90 Lari and thereafter rules as set out in this document. In case a situation buys one drug which costs 20 Lari with a 50% is unclear or not described in this administrative reimbursement. The patient receives a reimburse- rules, the case has to be discussed with the Drug ment of 50% of 10 Lari (the difference between Polis before action is taken or patients are given 90+20=110 Lari and 100 Lari). certain rights. The Booklet is stamped on the front page indicating 5.2 Authorized pharmacies are recognizable from out- that the 100 Lari minimum has been reached. side of the pharmacy with a special sticker. Unauthorized use of the sticker is prohibited. 4.14 After the patient has reached the 100 Lari limit, the patient shows the stamped Booklet at the prescrip- 5.3 Pharmacies will present the totaled reimbursement tion filling. The pharmacy compares the civil regis- bill after the end of each month to the Drug Polis, tration number on the Booklet and on the prescrip- together with the Pharmacy Reimbursement Form. tion. After this the prescription is filled as usual. 5.4 At the request of the Drug Polis the pharmacy The patient pays 50% and the pharmacy is adding should provide access to these prescription archives. the remaining 50% to the Pharmacy Reimbursement 5.5 Authorized pharmacies may receive a fixed advance Card. payment from the Drug Polis of app. 50% of the 4.15 With respect to any possibly later control of the estimated monthly reimbursement claim. Each patient’s reimbursement status the pharmacy can monthly invoice will be paid app. 2 months after take copies of the Booklet to keep at the pharmacy. receipt of the involve. 4.16 Original prescriptions are always kept at the phar- 5.6 At the turn of the year, reimbursements for the pre- macy. At the request of the Drug Polis they are to be vious year can be settled in connection with settle- shown for control purposes. ment for January. 4.17 A time limit for settling prescriptions will be fixed 5.7 In case of unclearity or disagreement about the to maximum 1 week after the doctor has issued the settlement of reimbursed items, cards or any other prescription. issue the Drug Polis should be contacted. The Drug 4.18 In case the pharmacy suspects either the patient or Polis will confirm a decision to the pharmacy in the doctor of unreasonable behavior or deliberate writing as soon as possible. falsification the pharmacy is obliged to inform the 5.8 The Drug Polis keeps record of questions, requests Drug Polis immediately. In any case two copies of and disagreements for later evaluation. the Booklet and the prescription are to be made of which one is kept at the pharmacy and the other has to be sent to the Drug Polis. 6. Information 4.19 In case the pharmacy, considering the total amount involved, finds the reimbursement unreasonable the The following material will be used as information to the pharmacy can refuse to reimburse and refer the patients: patient to the Drug Polis' office • A leaflet which can be distributed at the pharmacies 4.20 Each pharmacy will receive an updated list of regis- and possibly at the doctor’s and in polyclinics; tration numbers of lost Booklets. Pharmacies check each time when a Booklet is presented whether this • An information package for patients to be distributed card is on the list of lost cards. through the pharmacy network; 4.21 If the Booklet is on the lost cards list and the identi- • The Booklet will contain a short instruction about the fication number of the patient does not correspond, use of the card; the card is taken by the pharmacy and the pharmacy • Posters for the authorized pharmacies. will report to the Drug Polis. 4.22 If the card is on the list of lost cards and the identi- Furthermore press meetings will be held and articles fication number of the patient corresponds, the lost will be published in the local press. card is found and the pharmacy will report so to the Pharmacies and general practitioners will be in- Drug Polis. formed about the Drug Reimbursement System by the Drug Polis, among other things by receiving this note, the above mentioned information and samples of the patient card.
WHO, Special Project for NIS Copenhagen, October 1997
:+2 Special Project in NIS 2 Annex III Pharmacy administration record '58* 35(6&5,37,21 '58* 5(,0%856(0(17
32/,6 3KDUPDF\ $GPLQLVWUDWLRQ 5HFRUG
Issuing authority DRUG POLIS, Station street 3, Kutaisi
Pharmacy License Number Name Address
Billing Month ______- 1997 Pharmacy Stamp Total Billing ______Lari Date ___/___/_____
Instructions for use: Fill in the required information for each prescription drug from the national essential drug list of Georgia. This record is only needed when the patient receives a reimbursement amount. At the end of each month send this record (with the amount for that month totalled) signed, stamped and dated to the issuing authority together with an invoice. You will receive the total amount due within one month time. Note: Claims of non-prescription drugs or drugs not on the Georgian essential drug list will not be admitted.
Patient Card Medicine Expenditure Date Number Name Total price (Lari) Reimbursed (Lari)
Total to be billed
Copyright: Ministry of Health of Georgia, 1996 Form number 123456789
Annex V Kutaisi Communication Plan
Introduction
A communication plan defines communication target groups, indicates which media are most appropriate for each target group and takes into account the different stages and messages in the development process. It is clear that in each stage of the process from awareness till actual satisfaction with the product or service, good communication can contribute a lot to the success of any enterprise. Turning market potential into buyers or users and later into satisfied customers is a challenge. The communication process is determined by: communication target groups, stages of awareness, market potential, communication media, and communication mix
Stages in awareness Communication tools per stage of development (awareness) Stage Response Communication Media There are four stages from awareness to objective usage. These stages have different commu- Cognitive Attention To inform Free publicity nication objectives to achieve higher levels stage Awareness Seminars & presentations of consumer response. Each stage also dif- Knowledge Public relations fers in the kind of media to be used Posters Brochures Affective Interest To persuade Mailings stage Preference Leaflets Desire Advertising Point of purchase display Premiums and gifts Trial / Action To remind and Couponing purchase Trial tease Premiums stage Purchase Discounts Contests, sweepstakes Incentive programs Mailings Usage Word of mouth To confirm and Free publicity stage advertising reward Premiums Re-buy Discounts Satisfaction Incentive programs Mailings Membership programmes
Market potential
If we look at each stage and its effect on turning 100% 100% market market potential into actual users it becomes clear market that at each stage the (communication) effort should 80% aware be maximised in order not to loose to many potential 70% 80% aware users underway. tried 80% satisfied This figure indicates the potential losses at each stage 60% of making people (1) AWARE, (2) TRY and (3) tried SATISFIED with the service or product. The 50% introduction of the scheme therefore needs full satisfied attention and full communication to all target groups 21% of 51% of involved, where each target group may be addressed total total in different intensity at each stage. market market
Extra incentives
At each stage extra incentives may be used to attract attention, please people, keep the system alive. These incentives may consist of promotional items, extra benefits (free drugs if donated, free check-ups in polyclinics, etc.), sponsored items (s.a. information material about medicines, baby packages, medical aid kits, information about birth control, etc.).
WHO Special Project in NIS 1 Communication target groups Communication mix The following main target groups can be identified: The communication mix shows which message and which 1. Consumer - card buyers communication instrument (media) at each stage should be 2. Patients - card users applied to each target group. Communication of different 3. Pharmacy - point of sale, point of benefit stages can be combined in one effort and also different 4. Doctor / Polyclinic - point of sale, point of benefit target groups can be reached by one medium. 5. Politicians - Influentials, opinion leaders 6. Hospitals - Influentials The following table gives an overview of the possibilities. 7. Media - Influentials, communication instrument Of course the budget is forcing the set priorities and select those instruments (media) which are considered to be the most effective.
Communication mix for Kutaisi Reimbursement Pilot Stage Month Target groups Card buyers Patients Pharmacies Polyclinics Hospitals Politicians (card users) Doctors Awareness 8-9 T O INFORM message Announce something new, special - Important development, social project - Factual information instruments Free publicity yes yes yes yes yes yes Seminars yes yes Public relations yes yes yes yes Posters yes yes Brochures yes yes yes yes Intention, desire 9-10 T O PERSUADE message Show direct benefits for participation and involvement - Create sensation and excitement instruments Mailings yes yes Leaflets yes yes yes yes Advertising yes Shop yes yes yes yes Display yes yes yes yes Premium/gift yes Trial / purchase 9-10-11 T O REMIND AND TEASE message Satisfaction if bought Information about number of users Dissatisfaction if not bought Satisfaction and opinion of first users instruments Couponing yes Premiums yes yes yes Discounts yes Incentives yes yes yes Mailings yes yes yes yes yes Use 11--> T O CONFIRM AND REWARD message Success of benefits - Success of benefits for users and suppliers Examples of non-card excessive cost instruments Free publicity Yes yes yes yes Premiums yes yes yes Discounts yes Incentives yes yes yes Mailings yes yes yes yes Member progr. yes yes yes
WHO, Special Project for NIS Copenhagen, October 1997
WHO Special Project in NIS 2 Annex VI Communication samples
Small poster (English version)
DRUG POLIS DRUG POLIS Get GetGet your your DrugDrug
PolisPolis now! now! What do you get? What– do10% you discount get? on prescription drugs – – 50%10% reduction discount on on prescription prescription drugs drugs after you – have50% bought reduction for 80on Lari prescription drugs after you – 25%have price bought reduction for 80 for Lari doctors visits – 25% price reduction for doctors visits Who can participate? Who can participate? – all adults and their families – – childrenall adults up andto 16 their years families are included – children up to 16 years are included What should you do? What should you do? – Obtain a Drug Polis Booklet at your municipality – Obtain a Drug Polis Booklet at your municipality What does it cost? What– doesfrom 4 itLari cost? for one adult to 8 Lari for 4 adults – from 4 Lari for one adult to 8 Lari for 4 adults The Drug Polis programme is supported by the World Health Organization, Kutaisi Region, Ministry of Health of Georgia, The World TheBank, Drug Postbank, Polis programme Pharmacy I,is Pharmacy supported II,by Pharmacythe World III,Health Pharmacy Organization, IV, Pharmacy Kutaisi V, Region, Polyclinic Ministry A, Polyclinic of Health B, of Polyclinic Georgia, C.The World The CommitteeBank, Postbank,of Recommendation Pharmacy consistI, Pharmacy of Mr. II, XX, Pharmacy Mayor of III, Kutaisi Pharmacy City, IV,K. Barkaya,Pharmacy Member V, Polyclinic of Parliament, A, Polyclinic R. Makharadze, B, Polyclinic Drug C. The Committee of RecommendationDepartment consist MoH, of Ms.Mr. D.XX, Sheila, Mayor Health of Kutaisi Directorate City, K. KutaisiBarkaya, region, Member ...... of Parliament, R. Makharadze, Drug Department MoH, Ms. D. Sheila, Health Directorate Kutaisi region, ...... TakTakee ccareare of your family’s health TakTakee ccareare of your family’s health
Booklet (English version)
World Health D R U G OrganizationWorld Health D R U G RegionalOrganization Office for RegionalEurope Office for Europe P O L I S P O L I S Drug reimbursement Kutaisi bookletDrug reimbursement nr: ______Kutaisi booklet nr: ______Kutaisi Regional HealthKutaisi Authorities Regional Health Authorities
DRUG POLIS Foundation 3 StationDRUG square, POLIS Kutaisi Foundation phone:3 Station 12345 square, Kutaisi phone: 12345
WHO Special Project in NIS 1 Annex VII
Kutaisi, 1998
Sociological Research Full Report
Marine Chitashvili Faculty of Psychology Tbilisi State University 1, Chavchavadze Ave. 380079 Tbilisi Georgia
Sociological Research Full Report
Table of contents
Table of contents...... 2
A. Research method ...... 3
Stage 1 - preparatory work...... 3 Stage 2 - field work...... 4 Stage 3 - final data processing, analysis, results and report on the conducted research...... 5 B. Report of research results ...... 6
Research objectives...... 6 Sample...... 6 Chart 1. Target groups for the sociological research...... 6 Chart 2. Frequency distribution of respondents by target groups ...... 6 Members versus non-members...... 7 Chart 3. Employment of policy members and non-members (V6)...... 7 Chart 4. Average monthly income by the end of December 1998 ...... 8 Chart 5. Frequency of visits to a doctor and issuing prescriptions ...... 8 Non-members willingness to join ...... 8 Chart 6. Do you want to join the Drug Policy (non-members) (V16)...... 9 Chart 7. Proposal of the drug policy to others (close people) from the members (V30)...... 9 Drug Polis membership factors...... 9 Chart 8. Membership factors (from situational to full awareness. V 30)...... 10 Public awareness...... 11 Chart 9. Public knowledge about the programme (non-members)...... 11 Chart 10. How we learned about the Drug Policy (V17) ...... 11 Areas for improvement...... 12 Chart 11. Perceived weaknesses of the Drug Policy...... 12 Chart 12. Drug policy improvement aspects...... 12 Spending ...... 13 Chart 13 . Average monthly spending on medication ...... 13 Chart 14. Monthly spending per target group ...... 13 Assessment of the effectiveness of the drug policy programme ...... 13 Chart 15. Are the discounts and services offered by the Drug Polis system beneficiary for you?.... 14 Chart 16. Do you know people that have a card, and what is their opinion? ...... 14 Motivation of current members ...... 15 Chart 17. Reasons for becoming a policy member (V25)...... 15 Chart 18. The frequency of using the booklet by members (V 27) ...... 15 Chart 19. Comments on the sale of the book (V26), and the service in the pharmacy store (V 28). 15 Conclusions...... 16 Annex Questionnaire...... 18
2 Sociological Research Full Report
A. Research method
The work involved in the sociological research comprised three stages: Stage 1 - preparatory work: preparation of a final version of the questionnaire, printing questionnaire forms, interviewers' training, preparation of a sample. Stage 2 - filed work: interviewing Stage 3 - data processing, expert assessment of open-end questions, preparation of a final report. All these activities were carried out with minor alterations regarding sample prepa- ration.
Stage 1 - preparatory work 1) A one day seminar on the preparation of a final version of the questionnaire with the participation of four experts (two psychologists and two sociologists). During the seminar the project coordinator provided the experts with the information on the objectives, tasks and targets of the future research. The experts were distributed the first version of the questionnaire form for proc- essing. The two thirds of the seminar were dedicated to the discussion of the form and the adoption of its final version. The discussions revealed the fact that there was no correspondence between the questions of the Georgian and English versions, which was caused by the following: In some cases the Georgian text was not precisely translated. This applies to the following questions of the original, English version of the questionnaire: 3,8,15,16,17,18, 22, 24. These questions were corrected against the English version. The Georgian version contained additional questions as compared to the English version. These questions were included into the final version of the questionnaire without alterations. (a) Besides, three additional questions were added to the final version: V2a - gender, V7 - income and V31 - the subject's awareness level when partici- pating in the "Drug policy" programme. The awareness scale (V 31) was created in the course of the seminar. It is a 7 grade scale which covers different levels of awareness ranging from situational factors ("I am fasci- nated by the advertisement" V 31.1) to completely logical operations ("I made preliminary calculations of my profit" V31.7). (b) The team of experts elaborated a standard general instruction for the inter- viewers to deal with the respondents. The instruction was placed on the first page of the questionnaire. Several questions also underwent alterations in terms of design. For instance, Q24 from the original version was split into variables V3 and V39 in accordance with the requirements of the soft- ware for data processing. (c) By the end of the seminar the experts' team developed the final version of the questionnaire as well as the criteria system for the selection of those individuals, who would be desirable and relevant candidates for the future research (focus group). The recommendations developed at the seminar for
3 Sociological Research Full Report
respondents selection were included in the interviewers' training. During the training instructions were given by the project coordinator. (2) A new version of the questionnaire was printed in 350 copies (3) Sampling. According to the project the project coordinator and the sociologist were supposed to go to the field for sample selection so that the interviewers would get finalized lists. The organization implementing the "Drug Policy" (the foundation "Tanadgoma") was not able to receive us or ensure necessary conditions for sampling. In that period (December 15-23) the Foundation's activity was checked by the tax service. At the Foundation's request we had to postpone our first business trip to Kutaisi for almost 10 days and to wait to its agreement regarding the identification of the sample necessary for the research. The first trip to Kutaisi which envisaged the project coordinator's and the sociologist's work on sampling (random sampling based on the programme data base) did not take place due to the departure from the schedule. For this reason we changed the sampling principle. This time we decided on quota sampling and the territorial unit, on which were located pharmacy stores and budgetary organizations covered by the "Drug Policy" programme. These stores and budgetary organizations were those with a high percentage of policy owners. It should be also mentioned that the leader of the interviewers' team also had to select a sample. It turned out that for some technical reasons the data base only comprised 600 people which made it impossible to use this base considering the territorial principle (i.e. by streets). In this context we would like to make a comment that in the case of project follow-up a special attention should be given to information support, since, otherwise it will be absolutely impossible to apply the random sampling principle which is necessary for sociological research. (4) Interviewers' training - the training programme provided for the training of 8 interviewers for field work. Even though the programme provided for 5 inter- viewers 3 additional people underwent training to rule out situational factors like interviewers' illness, some unexpected events, etc. Out of the three candi- dates one was supposed to be the project coordinator / leader of the interview- ers' team and the other two had to work as interviewers. The first half of the training was dedicated to the use of the interviewing tech- nique by all participants and demonstration. An emphasis was made on open- end questions and the information obtained via these questions. The criteria system for the selection of candidates for the future focus group was presented and learned separately. Special training material was distributed to the inter- viewers. The second half of the training was devoted to communication skills, role playing and the elaboration of the relevant coping strategies for possible situations. The interviewers were distributed special stationary both for the training and the field work.
Stage 2 - field work. The field work was performed from December 25 to December 29 (inclusive) 1998. Only 6 people were engaged in the field work - 5 interviewers and the leader of the interviewers' team, a professional psychologist. During the research process the project coordinator was also in Kutaisi (26-29 December). 308 interviews were conducted in total. The sample was fully interviewed for all target groups (50
4 Sociological Research Full Report people in each). At the end of each day comparative data analysis was made in respect of open-end questions and sampling. In parallel, the project coordinator and the team leader were preparing material for a group of experts, that was supposed to process the material obtained through open-end questions when drafting the final report. A main and specific work related difficulty was finding the sample at widely spread addresses (the first version of the sample prepared for us at the local office). Very often the respondents on the list either no longer lived at that address or did not want to participate in the interview. These were the difficulties that caused the replacement of the random sampling principle with the quota principle. The field work was completed on December 29. On December 27-28 the project coordinator familiarized herself with the data base of the "Drug Policy" located in the pharmacy shop "Sanimusho". (I have not seen the full data base and the head- quarters of the Tanadgoma foundation since I was told that due to some technical problems the data base had been deleted in the computer). I familiarized myself with the advertising material used as printed material for the " Drug Policy". I saw the TV programme and personally met the President of Tanadgoma Foundation (project implementing organization) Mr. Ramaz Kerdzaya. By interviewing this person using a structured interview with open-end questions, we obtained infor- mation and learned about his future plans. It should be noted that the pharmacy shop "Sanimusho" (which means "exemplary" in Georgian) definitely justifies its name in terms of its design, range of offered products, sanitary standard and the quality of service. This opinion is shared by most respondents.
Stage 3 - final data processing, analysis, results and report on the conducted research. Data processing a) The data were captured through the SPSS 7.5. data base regular scheme and were processed using the corresponding software. The data were recorded using the Excel. All the data and written documentation (reports) were copied to a floppy disk b) a special seminar was held to analyze the information obtained through open- end questions and draw the relevant conclusions at the stage of data processing. The seminar was lead by the project coordinator . Four people participated in it (two psychologists - the training leader and the leader of the team of interview- ers and two sociologists - an expert of the sampling strategy and an independ- ent investigator). A one-day seminar was dedicated to data analysis and the formulation of final conclusions about interesting target objects identified by the research. c) preparation and translation of the final report presented in Annex II.
5 Sociological Research Full Report
B. Report of research results
Research objectives On December 25-29, 1998, sociological research was conducted in Kutaisi. The research aimed at the investigation of the Drug Policy Programme implemented in Kutaisi. Research objectives were the following: 1. learn about the level of population's awareness of the programme 2. identify the factors determining the participation in the programme (informa- tion supply ways and means, organizational sub-units of the programme, etc.). 3. identification of strong and weak aspects of the programme (feedback from the population, its expectations regarding the programme)
Sample A special form was elaborated for this purpose. The form included 31 questions and was intended for the following sample.
Chart 1. Target groups for the sociological research
Target group Group Members Group Non- Profile Number Sample Number Members Sample Mothers (aged 20-40) 1 50 4 50 with children Adults (above 55) 2 50 5 50 without children Other 3 50 6 50 without children
308 people were interviewed in the framework of the present sociological research. Out of them 151 were members and 157 non-members. Their distribution by target groups is shown in the chart below (1-3 indicates member group and 4-6 non- member group). The number of each group is indicated in Chart 1.
Chart 2. Frequency distribution of respondents by target groups
60 51 51 49 53 50 54 50 40 30
Amount 20 10 0 1 2 3 4 5 6 Group Number
The questionnaire included open and closed questions. Here we present only those results that are statistically significant for closed questions. Responses to open
6 Sociological Research Full Report questions are generalized on the basis of expert assessment (The report does not include all the results of statistical analysis.
Members versus non-members Data analysis shows that policy members and non-members differ in terms of employment (V6). The chart below presents these data.
Chart 3. Employment of policy members and non-members (V6)
0% 10% 20% 30% 40% 50% 60% 70%
19.6% 11.3% V6.1. - Both spouses 6.3% employed 8.9% 18.4% 5.7% 43.1% 58.5% V6.2. - One of the 31.3% spouses employed 40.0% 51.8% 52.8% 37.3% 30.2% V6.3 - No one 62.5% employed 51.5% 30.6% 41.5%
1 4 2 5 3 6
Chart 3 shows that in the case of V6 all the differences are statistically significant (p<0,014). This means that employment and the membership of the "Drug Policy" are interrelated. Policy members are those people in whose families either both spouses are employed or neither of them is employed. There are fewer policy members in the households where one of the spouses is employed. Such a picture might be caused by the fact that policies were distributed at working places or were provided to the socially unprotected part of the population (the unemployed). They were distributed free in budgetary organizations which actually ruled out any ini- tiative on the part of the population. Policy members often said that in spite of being policy book owners they had never used it, even though it was successfully used by others (co-workers, acquaintances). This points to the fact that drug policy participant target groups were not appropriately identified in terms of the benefits to be received through this insurance system. The number of people in need of more help was quite small (patients with chronic disease, representatives of vul- nerable groups, etc). Becoming a drug policy member was a mere formality. Membership at the expense of budget organization staff only increases the number of those covered by the drug policy but the exercise and programme loose their significance ("I know nothing about it. We were just distributed policies there, so I took it home", and the statements like this).
7 Sociological Research Full Report
Policy members and non-members do not differ in terms of household income. In general, these groups are distributed by income as follows:
Chart 4. Average monthly income by the end of December 1998
More then 100 Lari 6.2%
61 - 100 Lari 13.0%
41 - 60 Lari 19.8%
21 - 40 Lari 23.7%
11 - 20 Lari 21.1%
10 Lari 6.2%
0% 5% 10% 15% 20% 25%
Chart 4 shows that the population's average monthly income fluctuates between 20 and 60 Lari. There is no difference between policy members and non-members regarding the frequency of visits to a doctor and getting prescriptions. The general picture is the following:
Chart 5. Frequency of visits to a doctor and issuing prescriptions
75.9% 78.0% 80% 60% 40% 24.1% 22.0% 20% 0% Yes No V8. Visit to a doctor in the last month V9. Issuing a prescription
Chart 5 clearly points to the fact that visits to a doctor that are quite rare (V8) do not always end in getting a prescription (V9). This suggests that any medicine can be obtained at a lower price without a prescription comparing with what the policy offers the consumer. On the other hand it is evident that such a free medicine market does not oblige the doctor to make a prescription.
Non-members willingness to join As for Drug Policy non-members their 61,9% is willing to join the programme. V16 (Do you want to join the Drug Policy) is distributed by non-members in the following way:
8 Sociological Research Full Report
Chart 6. Do you want to join the Drug Policy (non-members) (V16)
Ye s 61.9%
38.1% No
0% 20% 40% 60% 80%
As for the members, the extent to which they advertise the Drug Policy (V30 - Do you propose to your close people to become members - the question actually measures satisfaction with the Drug Policy Programme) our results show quite a negative attitude (see Chart 7).
Chart 7. Proposal of the drug policy to others (close people) from the members (V30)
71.4% V30.1 - have not 81.6% proposed 66.7% 20.0% V30.2 - have 8.2% mentioned 15.7% V30.3 - advised to 26.5% apply for 10.2% membership 17.6% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
1 2 3
Chart 7 suggests that most drug policy members have quite an indifferent attitude towards the programme. They do not even mention it as a new system of privileges (V30.1; V30.2). Those with a more positive attitude towards the programme (V30.3) belong to the first and the third groups. The results are statistically signifi- cant by 0.045.
Drug Polis membership factors The results suggest that the value of the programme is insufficiently understood by the members themselves. There are several factors for this: some do not think that it meets the consumer's expectations (benefits), others have a lack of information, some misunderstanding may have been caused by the various changes in the Polis during the first stages of its implementation, and the substantial number of booklets that are not used. Drug Polis competes with policies of out-patient and especially in-patient hospitals (this comparison is often made). In these concurrent cases the payment is much higher, but there is more room for benefits when they are necessary. Mainly because they are largely subsidized by the state. For instance, the out patient policy (for a limited group of the vulnerable population) implies free examination twice a
9 Sociological Research Full Report year. The in-patient hospital policy implies free accommodation and benefits in the course of treatment). Although these polices have a limited coverage, their benefits may be substantial once used. The respondents' answers show that they do not know which pharmacy stores are covered by the programme or whether it is possible to get a medication in all the pharmacy stores under the programme. The respondents do not know the list of drugs to which a discount applies and often say that the medicine they need is not available at reduced prices (e.g. antibiotics). When we saw the list of drugs it became obvious that consumers were not always told about discounts applied to the drugs included in the price reduction under the programme. Pharmacy stores had not put up a full list of drugs. A list of the pharmacy stores covered by the programme and their addresses, terms of reduction is hard to obtain. Finally it can be concluded that the programme looses a market due this lack of information. The programme may also loose its credibility in the view of its own members. The research shows that the programme could be redesigned for different target groups, with different benefit schemes. A 10% discount for every group is consid- ered insufficient for many. Pharmacies’ negative reaction when presented with the policy and monthly savings (V.11) of 50 Tetri (50.5%) or at maximum one Lari (18.5%) do not always meet consumers' expectations. Some consumers become dissatisfied and loose their confidence in the programme. If we say that even the minimum monthly saving of 50 Tetri equals to 6 Lari in one year and saving totals 4 Lari, such a calculation requires high awareness on the part of the consumer. V31 measured to what extent the members were aware of drug policy related privileges and its effectiveness, whether it was a situational decision or a conscious behavior. Frequency distribution revealed the following:
Chart 8. Membership factors (from situational to full awareness. V 30).
V30.7 3.5% V30.1 fascinated by the V30.6 1.4% advertisement; V30.2 was advised by others; V30.5 4.2% V30.3 like to take a risk; V30.4 60.4% V30.4 possibility of discount; V30.3 4.2% V30.5 realized that would save V30.2 22.9% money; V30.1 3.5% V30.6 tried to calculate the saving; V30.7 made precise preliminary 0% 20% 40% 60% 80% calculations of everything.
Chart 8 clearly shows that joining the drug policy is a matter of the expected discounts for the consumer (V30.4) and is also largely determined by the social influence factor (V30.2). When social influence shows such a high indicator as compared to all the other external indicators it would be beneficial for the pro- gramme to use advertising agents. It should be noted that members' target groups (1-3) did not differ in the awareness level and Chart 8 reflects a general regularity.
10 Sociological Research Full Report
Public awareness The questionnaire enabled us to learn to what extent Kutaisi public was informed about the Drug Policy Programme (V14 - have you ever heard about the drug policy and V15 - do you want to get information). Non-members served as infor- mation source for variables 14 and 15. The chart below shows public awareness.
Chart 9. Public knowledge about the programme (non-members)
66.7% 70% 62.5% 61.9% 60% 50% 38.1% 40% 37.5% 33.3% 30% 20% 10% 0% V 14 - have you V15 - Do you wantV 16 - Do you want Yes No heard to get information to become a member
Chart 9 shows that the public is definitely aware of the drug policy (V14 - yes 62,5%) and out of them 61,9% (yes to V 16) wants to join. Out of those who are unaware of the drug policy (V 14 - no 37,5%) 66,7% (yes to V 15) is interested in the information about the programme and will listen to it. The continuation of the drug policy programme is justified by the existence of the interested consumer. There are three main sources of the information on the Drug Policy (V 17). These are: Colleagues, friends or family members (V17.05); Chemists (V17.07); Town or municipality (V17.08) Chart 10 presents those frequencies which refer to information source for the drug policy programme. All the differences are statistically significant (p 0.000)
Chart 10. How we learned about the Drug Policy (V17)
2.9%
Other 24.0% 21.9% 5.0% Chemists Town or municipality 24.8% 8.0% 7.0% In or out patient hospital Newspapers 9.5% 4.1% TV advertisement Colleagues, friends, family members TV programmesPosters 0% 5% 10% 15% 20% 25% 30%
Open questions V18 and V19 were used to identify what important information is memorized, including positive points about the drug policy advertisement. The analysis of the information obtained through open questions says that the respon- dents remember the privileges, the progressive system of price discount or a possi-
11 Sociological Research Full Report bility of getting drugs free. Some responses were not characteristic of the entire frequency (e.g. I cannot remember the drug name). "I don't remember. It was long ago" - was quite a frequent answer. This directly points to the fact that the adver- tisement should be of a regular character. A brief and attractive TV roller will be able to permanently attract public attention.
Areas for improvement The respondents name the following weaknesses of the Drug Policy:
Chart 11. Perceived weaknesses of the Drug Policy
· Information perceived as unreliable · Lack of advertisement · Advertisement is not refined · Correspondence of the advertisement with the reality (the advertisement is not based on correct or precise information) · The system of privileges is presented in an ambiguous way · Small discount · The advertisement is difficult to understand · TV is a limited source due to power cuts
It should be specially mentioned that the sample remembered well the TV pro- gramme, but the information obtained through advertisement was impossible to obtain. The reason for such weak memory or such an unsatisfactory advertisement was impossible to determine since we were not able to see advertisement rolls on the drug policy. (They were not demonstrated during the meeting with the Drug Polis project team. We saw the TV programme which is very well made and according to the sample is very well remembered). Our recommendation is that it is necessary to have an advertisement roll, which would be broadcast regularly at an optimal time in terms of the power supply schedule (It should be noted that the power supply schedule is extremely stable in Kutaisi). 35% of the respondents put that the information is presented in an ambiguous way. The major problem is to get information, but if it will be received by the booklet it is fine. In this case the booklet should be very easy to get. As our experience shows if the booklet is nice and easy to get it has the same effect for the advertising as other sources. So it will be great if you will put the booklets everywhere. The chart below refers to the improvement of the drug policy programme (V22).
Chart 12. Drug policy improvement aspects
1 understandable information 19.8 % 2 easy application for membership 7.0 % 3 complicated programme 2.1 % 4 free medicine 11.6 % 5 low prices 44.2 % 6 more compensatory drug lists 7.0 % 7 prescription problem 1.7 % 8 do not know - 9 any kind of medicine should be available in the pharmacy store 3.3 % 10 other 3.3 %
12 Sociological Research Full Report
As the chart shows, the main demand is to lower the prices (44.2%) rather than obtain medication free (11.6%). The data show that the populations requires a bigger reduction rather than free distribution of medicine. These data are supported by the following: annual payment of 2 Lari (V 22) is acceptable for 51.2% of the sample, is too expensive for 11.6% and free delivery is required by 37.2%. The difference between these three pieces of data is significant and equals to 0.011. 52.7% believes in the drug policy programme whereas 47.3% does not trust it (V24).
Spending The average monthly amount spent by the entire sample on medication is the following (V 11):
Chart 13 . Average monthly spending on medication
1 0-5 Lari 50.5 % 2 6-10 Lari 18.5 % 3 11-15 Lari 6.9 % 4 16-20 Lari 7.3 % 5 21-30 Lari 6.3 % 6 31-50 Lari 5.2 % 7 51-100 Lari 2.3 % 8 100 and more 2.3 %
This implies that the average spending is approximately 13 Lari per month, which comes to roughly 10 USD. This includes OTC and all other expenditure in phar- macies, as it is difficult for consumers to assess what are pharmaceuticals and what not.
Chart 14. Monthly spending per target group
members non-members Mothers (20-40) Adults (55+) Other adults Mothers (20-40) Adults (55+) Other adults with children no children no children with children no children no children 0-15 Lari 71% 70% 73% 83% 84% 75% 16-30 Lari 18% 20% 11% 9% 10% 14% 31 Lari plus 12% 10% 17% 8% 6% 12% 100% 100% 100% 100% 100% 100%
Per target group the drug expenditure varies. Members have higher drug costs, so they may see clear benefits in Drug Polis. Of all respondents 60% is willing to be insured to cover high medicine costs (V12).
Assessment of the effectiveness of the drug policy programme The effectiveness of the drug policy programme in the consumers' opinion is measured by V 21 (whether the discount was beneficial) and V 23 (the opinion of drug policy members about the programme).
13 Sociological Research Full Report
Chart 15. Are the discounts and services offered by the Drug Polis system beneficiary for you?
40% 32.6% 35% 27.9% 30% 25% 19.1% 20% 15% 10.2% 10% 5% 0% for me, yes for my I don't need These children, yes these privileges are privileges not enough
Of the current members more than one-third considers the benefits enough. Some 20% says they do not need these ‘privileges’ and another one-third would like to receive more benefits from the Drug Polis. The opinion per target group about the benefits provides interesting results:
(1) Mothers (20-40): (a) 42% of the members find a positive motivation in the offered benefits, while 29% would like to have more benefits. (b) With the non-members even more mothers (54%) find the current benefits good for them or their children, while another 31% would like to see more benefits. (2) Adults (55+) without children: (a) 47% of the members find the current package attractive, but 43% wants more. (b) Of the non-members only 29% finds the benefits according to their needs, while only 24% says they would like more. A large part of these non-members (43%) says they don’t need these ‘privileges’.
This leads to the conclusion that the current Drug Polis addresses adults (55+) better than the mothers with children.
Chart 16. Do you know people that have a card, and what is their opinion?
60% 54.1% 50% 40% 30% 16.1% 17.4% 20% 12.4% 10% 0% I don't know Yes I do. Yes I do. Yes I do but I anyone They are They are not don't know quite satisfied their opinion. satisfied enough
Half of the people cannot name anybody who has a Drug Polis. The other 50% know people with a Drug Polis card, of which the number of satisfied users and not (enough) satisfied users is more or less balanced.
14 Sociological Research Full Report
There is a difference between members and non-members: 55% of the members know another person with a booklet, while only 32% of the non-members. This is especially true for the rest-group (members 70%, non-members 23%). With the adults (55+), there is not much difference in knowing somebody with a booklet, but non-members know more people that are satisfied (29% versus 10%). This again indicates that adults (55+) are more conscious in not becoming a member (they know about it, but do not need). The results also support the idea of using agents or other social mechanisms to inform or illustrate the Drug Polis.
Motivation of current members What are the main reasons of becoming a member and how are the booklets used?
Chart 17. Reasons for becoming a policy member (V25)
1 Discount and privileges offered by the pharmacy store 62.8% 2 Service and privileges offered by the out patient hospital 8.8% 3 Amount spent on medicine on a monthly basis 7.4% 3 To be insured for my children 7.4% 5 Other reasons 13.5%
Chart 18. The frequency of using the booklet by members (V 27)
0 times 56.1% The book is not widely used yet, which causes a 2-5 times 33.1% negative attitude and the devaluation of the pro- 6-10 times 8.1% gramme. Such an attitude on the part of member- 11-50 times 2.7% respondents is proved by the fact that there are 50 times and more 0% almost no comments regarding the sale of the book, or the service at the pharmacy store.
Chart 19. Comments on the sale of the book (V26), and the service in the pharmacy store (V 28).
68.2% 70% 60% V 26. Comments on sale of the booklets 50% 1. No 2. There are not many places to sell the 40% book 30% 3. The books are very expensive 20% 4. The information is not understandable 8.1% 10.1% 10% 6.8% 5.4% 5. The programme of privileges is not 1.4% explained well 0% 1 2 3 4 5 6 6. Other
90% 81.5% 80% 70% V 28: Comments on the service in the 60% pharmacy 50% 1. No 40% 2. The process is too complicated 30% 3. The pharmacy shop is not aware of 20% 14.0% the programme 6.8% 10% 5.5% 4.8% 4. The programme does not cover a 0% sufficient number of pharmacy shops. 1 2 3 4 5 5. Other
15 Sociological Research Full Report
Conclusions As for V 29 (Do you have any other comments) the data analysis clearly shows the main problems named by the respondents: medicine with an expired period or close to expiration; issuing the policy 1 month prior to its expiration; facilitation of the process; expensive medicine and insignificant discount. (As the respondents say there is a pharmacy store in "Bzholebi" with very cheap medicine. The prices are much lower there than in case of any policy with discount.) The respondents think that a prescription is too expensive so discount becomes senseless. The respondents feel embarrassed when showing the policy book, since they are neglected. They believe that the starting percentage of discount should be higher. They also think that it should be possible to trade on credit. The respondents very often say that they do not use the policy, because the phar- macy staff do not welcome them with policy cards ("again the policy", "and you with policy", "these policy holders you can't count" etc.) Nearly 40% of respon- dents pointing at the way how they are treated by pharmacists. It is necessary to train staff in pharmacy stores so that they treat book owners appropriately, without neglecting or insulting them. It turns out that the people most satisfied with the drug policy are those who often have to purchase medicine. Even the managers of the pharmacy stores covered by the programme knew nothing about the 40 Lari limit (pharmacy store #20). Infor- mation deficit is very acute. The drug policy is hardly differentiated from other policies. People forget that they are scheme members, involvement level is very low, the municipality does not advertise the drug policy scheme to attract public. The research suggests that the groups who really need the drug policy have not been differentiated yet. The entire scheme was not differentiated enough which caused a neutral attitude towards the drug policy scheme. A common requirement is to create a more flexible and differentiated system of privileges. We think that it is necessary to identify those in need of privileges before policy distribution. Such groups need to be identified (recording of contingent at out patient hospitals and pharmacy stores and determining those who require the policy). In the case of preliminary sampling will be provided real and intense assistance, which, in its turn, will serve as an advertisement for the programme. "The drug policy" should be put up on a special advertising board in every pharmacy store. The board should contain information about the pharmacy stores covered by the programme (addresses), programme description and a clear pres- entation of the privilege system under the programme with a list of medicine and its prices in USD since due to currency fluctuation the consumer is confused and has an impression that prices are going up instead of being reduced (I have person- ally witnessed this). Advertising should correspond to the programme and should be clear, well struc- tured and regular. A certain part of population is ready to participate in such a drug policy pro- gramme where much bigger amount is paid for the book, but the discount of 50% or above will be introduced from the very beginning. This is based on the observa- tion with respondents who have 'higher income' and even with lower income who state that if the discount will be real then may be they will pay for the policy. The
16 Sociological Research Full Report group with income 100 Lari and more could be the target group for such policy cards. The research shows that almost no co-ordination exists among the pharmacy stores within the programme. Therefore, in respect of an organizational structure it is necessary either to set up a large network of co-ordinated pharmacy stores or to entrust all the activities to a single store (e.g. "Sanimusho" is willing to serve this function. Consumers emphasize that this pharmacy store is exceptional indeed). It could be finally stated that the drug policy programme will become more effec- tive and successful if a) more publicity is insured along with clear information b) institution of advertising agents is set up c) a differentiated system of privileges is identified for target groups; d) a more co-ordinated organizational structure for programme implementation is set up e) the information and communication towards the public is refined (provide appropriate and easy to understand information more often). Qualified opera- tors are trained. f) different forms of drug policy are elaborated for different types of customers (e.g. once-off payment of a large amount followed by a large discount and privileges). The sociological research clearly shows that some technical aspects of programme implementation, implying the revision of the programme strategy and elaborating a new design need to be modified, which is a job of the relevant specialists.
17 Sociological Research Full Report
Annex Questionnaire
Form N Interviewer N
Respondent name (only for those covered by the programme) ______
Address ______
Date of Interview ______
Dear Sir/Madam, Hello. We are conducting survey ordered by the World Health Organization. The objective of this survey is to identify the impact of the Drug Polis Programme on your town, its strong and week aspects. Your co-operation and participation in the survey will help ensure future improvement of the named activity. Thank you for your assistance and support.
To interviewer: Make sure the respondent is resident in Kutaisi city. If not, immediately terminate the interview.
V1. Are you Drug Polis member or not? 1. Yes 2. No
V2. What is your age? ______years
V2a. Gender 1. Female 2. Male
V3. What is your family situation? 1. Single 2. Married, without children under 16 years
V3a. Married, with ______children under 16 years
V4. Assess or ask to which group the respondent belongs: 1. Mothers (20-40 years of age) 2. Senior ( >55 years age) 3. Other
V5. In which part of the city do you live? in ______
V6. Are you (or your husband) employed? 1. Both employed 2. Only one employed 3. No one employed
V7. What is your family's average monthly income? 1. 10 Lari or less 2. 11-20 Lari 3. 21- 40 Lari 4. 41-60 Lari 5. 61-100 Lari 6. 101 Lari or more
V8. Did you visit a doctor in the last month? 1. Yes 2. No
18 Sociological Research Full Report
V9. Did the doctor give you a prescription during the visit? 1. Yes 2. No
V10. Do you buy medicines regularly and what problems do you encounter? 1. I almost never buy medicine; I don't need 2. I almost never buy medicine; I cannot afford 3. I almost never buy medicine for other reasons 4. I buy medicines, without problems 5. I buy medicines, but pharmacies many times have not what I want 6. I buy medicines, but they are too expensive 7. I buy medicines, but in kiosks for a lower price 8. Other problems ______
V11. For how much money per month (on average) you buy drugs for you and your children? 1. 0-5 Lari per month 2. 6-10 Lari per month 3. 11-15 Lari per month 4. 16-20 Lari per month 5. 21-30 Lari per month 6. 31-50 Lari per month 7. 51-100 Lari per month 8. more than 100 Lari per month
To interviewer: If member go to V17. ______For non-members
V12. Would you like to have an insurance against high cost of medicine? 1. Yes 2. No
V13. Can you tell, please, why or why not? (To interviewer: Please, stress to say the reason of the choice) ______
V14. Have you heard of Drug Polis, the new drug compensation system? (To interviewer: If yes go to V16) 1. Yes 2. No
V15. There is a new insurance system called Drug Polis. Would you like to receive some information about that? 1. Yes 2. No
To interviewer: Provide information and end the interview who say NO in V1 and V14.
V16. Would you consider to become a member of this new Drug Polis? 1. Yes 2. No __
______For people who know:
To interviewer: ask everybody who say YES in V1 and V14.
19 Sociological Research Full Report
V17. How did you learn about Drug Polis for the first time? 01. by the posters in the city 02. by television programmes 03. by television advertising 04. from the newspaper 05. from the colleagues, friends or family 06. from the hospital 07. from my pharmacy 08. from the city or municipality 09. other
V18. What do you remember from the promotion or information you heard or saw? ______
V19. What was not good in the promotion about the Drug Polis system? ______
V20. Is an annual contribution of 2 Lari per person acceptable for you? 1. Yes, 2 Lari is acceptable 2. No 2 Lari is too much 3. No, it should be free of charge
V21. Are the discounts and services offered by the Drug Polis system beneficiary for you? 1. Yes, for me personally 2. Yes, mostly for my children 3. No, I don't need them at all 4. No, I consider them insufficient
V22. What aspects of the Drug Polis could be improved in your opinion? 1. Better information, I don't understand it at all 2. More selling points, difficult to become a member 3. Too complicated 4. All drugs should be free 5. Price should be lower 6. include more drugs for reimbursement 7. Prescriptions is a problem 8. I don't know, I just wait what others will say 9. All drugs should be at the drug store 10. Others
V23. Do you know people that have a card, and what is their opinion? 1. No, O do not know anybody with Drug Polis card 2. Yes, they are happy with it 3. Yes, they are not very satisfied 4. Yes, but I don't know their opinion
V24. Do you trust or believe in the "Drug Polis" programme?
1. Yes 2. No ______For members:
V25. What were the main reasons for becoming a member of Drug Polis? 1. The amount of money I spend on medicine 2. To be insured for my children 3. The benefits and discounts offered in pharmacies
20 Sociological Research Full Report
4. The benefits and discounts offered in polyclinics 5. other
V26. Do you have any complaints concerning the way the booklets are sold? 1. No 2. Yes, not enough selling points 3. Yes, too expensive 4. Yes, information not clear 5. Yes, little cooperation at the municipality 6. other
V27. How many times have you used the booklet? 1. 0 times 2. 1-5 times 3. 6-10 times 4. 11-50 times 5. more than 50 times
V28. Do have any complaints concerning the booklet or the way you are treated in the pharmacy? 1. No 2. Yes, too complicated 3. Yes, pharmacy does not know enough about it 4. Yes, not enough pharmacies included 5. other
V29. Do you have any other complaints or suggestions? ______
V30. Do you recommend the booklet or Drug Polis membership to friends or family? 1. No 2. Yes, I mention it to them 3. Yes, I try to encourage them
V31. Finally, what, in your opinion, was the primary reason for the involvement in the programme and the purchase of the "Drug Polis"? 1. I was fascinated by the advertisement and decided to take a chance the purchase could be beneficial. 2. I followed to friend's/colleague's/relative's/other's advice and became a member. 3. I like taking a risk. Trial is 50% of success. 4. It was a way of obtaining a discount. 5. I realized that this would enable me to save money on drugs. 6. I tried to calculate the extent of the discount generated by the insurance 7. I made precise preliminary calculations of all possible expenses and arrived at the conclusion that the drug polis was more effective and in the long run, would enable to save money.
21 Annex VIII Drug Polis Information System
Information system for administration of the Drug reimbursement programme in Kutaisi, Georgia.
This system is programmed in Access. Example lay-outs of Forms (Screens) and Reports are attached. The structure of the Tables and the content of each Table are presented here.
Table structure
Members Member types · Cardholder data · sorts of cards with card prices
Deliveries Suppliers · Drug purchases per · Pharmacies cardholder · Polyclinics
Relations · Team · Steering Cttee
The table Members uses the table Member Types The table Deliveries uses the table Members and Suppliers The table Relations is not connected to other tables.
WHO Special Project for NIS 1 In addition there are 2 tables, which are generated automatically: · My Company’s Information - Standard data about Drug Polis to be printed for various purposes · Switchboard - Menu to choose screens and reports on the computer.
The fields in the tables indicated on the next page are indicative. Fields may be added when there is a wish to include more information, although too many additions may make the system unmanageable.
Preferably all fields should contain the data in Georgian.
Reports (see annexes) are indicative. The presentation may be improved by adding new reports and deleting unnecessary information from the currently generated ones. This is up to the project team and can be changed quite easy. (Ask your Programmer for instructions on How to generate new reports).
Tables, fields and screens Table Fields Form or screen Member types MemberTypeID MemberDues Member types MemberType Members MemberID MemberDues Members LastName DateJoined FirstName DateFull MemberTypeID Age WorkCompany Childrennames HomeAddress Cardrelations HomeCity AmountPaid HomePhone Limit Faxnumber Remarks Deliveries DeliveryIID Drug name Deliveries Shipdate Quantity Deliveries subform MemberID Total price SupplierID DoctorName Suppliers SupplierID City Suppliers SupplierName PhoneNumber ContactName Faxnumber Address Notes Relations ContactID Country Relations FirstName WorkPhone LastName HomePhone Address FaxNumber City Emailname My Organizations Standard My Organizations Information Information Switchboard Main Swichboard · Reports Main Switchboard + · Cardholders · Cardholders alphabetical subswitchboards · Cardholder data · Cardholders by number · Cardholder types · Cardholder types · Drug purchases · Drug consumption · Exit · Drug Polis suppliers · Suppliers and Relations · Drug Polis relations · Suppliers · Drug Polis Foundation · Relations · Exit · Exit · Change Switchboard Items · Exit database
Frans Stobbelaar WHO Copenhagen, 1 September 1997
WHO Special Project for NIS 2 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa
Annex IX programa "wamlis polisi"
SeRavaTian fasebSi gasaSvebi medikamentebis nusxa
analgeziuri, sicxis damwevi, arasteroiduli da steroiduli anTebis sawinaaRmdego da podagris samkurnalo saSualebebi
saerTaSoriso saxeli savaWro saxelwodebani ACETYLSALICYLIC ACID acetilsalicilis mJava aspirini, kolfariti, aspro, acilpirini, jasprini. ALLOPURINOL alopurinoli alopurinoli, ziloriki, purinoli. COLCHICINE kolxicini kolxiciniþ DICLOFENAC SODIUM diklofenak natriumi diklaki, voltareni, ortofeni, revodina, naklofeni*, revmaveki. INDOMETHACIN indometacini indometacini, meTindoliþ METHYLPREDNISOLONE meTilprednizoloni medroli, metipredi, prednoli*, urbazoni, meTilprednizoloni. PARACETAMOL paracetamoli acetaminofeni, eferalgani, panadoli.
dafalgani, volpani, tilenoli*. IBUPROFEN ibuprofeni brufeni, motrini*, iburpofeni. PIROXICAM piroqsikami algitrati*, androqsikami*, pronaqseni*, piroqsiflami*, piroqsikami. PHENYLBUTAZONE fenilbutazoni da misi Semcveli butadioni, butalani*, butalgini*, preparatebi. panazoni, reopirini, pirabutoli. TRIAMCINOLON triamcinoloni berlikorti, kenokorti, kenologi, polkortoloni. PREDNISOLONE prednizoloni prednizoloni, dekortini*, solu- dekortini*. antidotebi da mowamvlis sawinaaRmdego sxva saSualebebi CHARCOAL ACTIVATED gaaqtivebuli naxSiri gaaqtivebuli naxSiri METHIONINE meTionini meTionini PENICILLAMINE penicilamini kuprenili, penicilamini. DIMERCAPROL dimerkaproli dimerkaproli* SODIUM THIOSULPHATE natriumis Tiosulfati natriumis Tiosulfati
epilefsiis samkurnalo saSualebebi CARBAMAZEPINE karbamazepini karbamazepini, karbatoli, tegretoli, timonili*, finlefsini. ETHOSUXIMIDE etosuqsimidi etosuqsimidi*, suqsilepi PHENOBARBITAL fenobarbitali luminali, fenobarbitali. PHENYTOIN fenitoini dilantini*, difenini. DIAZEPAM diazepami diazepami, valiumi, relaniumi, sibazoni, seduqseni, faustani. VALPROAT SODIUM valproat natriumi depakini, konvuleqsi. programa "wamlis polisi"" 1 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani CLONAZEPAM klonazepami antelepsini, klonopini, rivotrili.
ìàüêàåóðè àìòènawlavuri antihelminturi saSualebebi MEBENDAZOLE mebendazoli vermoqsi, vormini*. PIPERAZINE piperazini piperazinis adipinati PYRANTEL piranteli kombantrini, nemocidi.
antibaqteriuli saSualebebi AMOXICILLIN amoqsicilini amoqsicilini, gonoformi*, roscilini, Standacilini, xikoncili*. AMPICILLIN ampicilini da misi Semcveli ampicilini, pentreqsili, ampioqsi. preparatebi BENZATHINE benzaTin benzilpenicilini bicilini-1, benzaTin benzilpenicilini. BENZYLPENICILLIN BENZYLPENICILLIN benzilpenicilini benzilpenicilinis natriumisa da kaliumis marilebi FLUCLOXACILLIN flukloqsacilini flukloqsacilini PENICILLIN-PROCAIN prokain benzilpenicilini prokain-penicilini PHENOXYMETHYLPENICILLIN fenoqsimeTilpenicilini penicilin-fau, ospeni. PIPERACILLIN piperacilini isipeni CEFOTAXIME cefotaqsimi klaforani, cefantrali*. CHLORAMPHENICOL qloramfenikoli levomicetini, sintomicini. CIPROFLOXACIN ciprofloqsacini ciprinoli, ciprobai, ciprodari, cifrani, ciproleti*. CLINDAMYCINE klindamicini dalacini, klimicini*, klindacini*. CO-TRIMOXAZOLE ko-trimoqsazoli baqtrimi, biseptoli, oriprimi, sulfametoqsazoli+trimeto-prini* DOXYCYCLINE doqsiciklini doqsiciklini, vibramicini. ERYTHROMYCINE eriTromicini erik, eritrani, eriTromicini. GENTAMICIN gentamicini garamicini, gentamicini, septopali.
CEFAZOLIN cefazolini cefamezini, gramaqsini*, kefzoli. KANAMYCIN kanamicini kanamicini NITROFURANTOIN nitrofurantoini furadonini, makrodantini*. NALIDIXIC ACID nalidiqsis mJava negrami, nevigramoni. SULFADIMETHOXIN sulfadimeToqsini depot-sulfamidi*, sulafadimetoqsini.
SALAZOSULFAPYRIDINE salazosulfapiridini sulfasalazini NITROXOLIN nitroqsolini 5-noki LINCOMYCIN linkomicini linkomicini FURAZOLIDONE furazolidoni furazolidoni tuberkulozis samkurnalo saSualebebi ETAMBUTOL etambutoli kombutoli, miambutoli, temibutoli*.
ISONIAZID izoniazidi izoniazidi, tubazidi*. PYRAZINAMIDE pirazinamidi pirazinamidi, tizamidi. RIFAMPICIN rifampini benemicini, rifadini, tubocini. STREPTOMYCIN streptomicini streptomicini, trobicini.
programa "wamlis polisi"" 2 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani antimikozuri saSualebebi AMPHOTERICIN B amfotericin-B amfotericin-B, fungizoni. GRISEOFULVIN grizeofulvini grizeofulvini NYSTATIN nistatini nistatini LEVORINE levorini levorini MICONAZOLE mikonazoli mikonazoli CLOTRIMAZOL klotrimazoli kanesteni, mikosporini. antiprotozouli saSualebebi METRONIDAZOLE metronidazoli flagili*, metronidazoli. trixopoli, metrojili, klioni. DILOXANIDE diloqsanidi diloqsanidi* TINIDAZOL tinidazoli faziJini, tinidazoli. antivirusuli saSualebebi
ACYCLOVIR acikloviri acikloviri, viroleqsi, zoviraqsi. ZIDOVUDINE zidovudini azidotimidini, retroviri, zidovudini*.
programa "wamlis polisi"" 3 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani Sakikis sawinaaRmdego saSualebebi ERGOTAMINE ergotamini ergotamini, kornutamini*. parkinsonizmis samkurnalo saSualebebi BROMOCRIPTINE bromokriptini bromergoni, bromokriptini, parlodeli,
BENZHEXOL benzheqsoli benzheqsoli, parkopani, ciklodoli. LEVODOPA+CARBIDOPA levodopa+karbidopa levodopa+karbidopa, nakomi. antianemiuri saSualebebi FOLIC ACID folis mJava folis mJava HYDROXOCOBALAMIN hidroqsokobalamini vitamini-b-12, oqsikobalamini. FERROUS SALTS rkinis marili rkinis sulfati, feropleqsi, ferum leki.
antikoagulantebi da maTi antagonistebi HEPARINE heparini heparini PHYTOMENADIONE fitomenadioni fitomenadioni PROTAMINE SULPHATE protamin sulfati protamin sulfati WARFARIN varfarini varfarini*
Aangioproteqtorebi ETAMSYLAT etamzilati etamzilati, dicinoni. cxenis wablis wyal-spirtiani nayeni eskuzani
Gplazmis Semcvleli saSualebani da plazmis fraqciebi specifiuri gamoyenebisaTvis DEXTRAN deqstrani deqstrani, makrodeqsi*, poliglukini.
POLYGELINE poliJelini poliJelini* ALBUMIN HUMAN albumini albumini
parenteraluri sakvebi saSualebebi AMINOACID aminomJava aminomJava
programa "wamlis polisi"" 4 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani gulsisxlZarRvTa sistemaze moqmedi saSualebebi
ISOSORBIDE DINITRATE izosorbid dinitrati etidinizi, izodiniti, izoketi, izosorb retardi, nitrosorbidi. NIFEDIPINE nifedipini adalati, kordipini, kordafeni, korinfari, fenigidini. NITROGLYCERIN nitroglicerini nit-reti, nitrominti, nitro maki, nitrongi, nitrogranu-longi, sustak forte, sustoniti. PROPRANOLOL propranololi anaprilini, inderali, obzidani. CHINIDIN qinidini kinilentini, qinidini, qinipeki*. DISOPYRAMIDE dizopiramidi ritmileni, ritmodani*, norpeisi. VERAPAMIL verapamili verapamili, izoptini, finoptini. CLONIDINE klonidini klofelini, katapresani, hemitoni. DIGOXIN digoqsini digoqsini, lanikori, lanoqsini. DIPYRIDAMOLUM dipiridamoli kurantili, persantini. LIDOCAIN lidokaini lidokaini PENTOXYPHYLLIN pentoqsifilini agapurini, ralofeqti*, trentali.
anTebisa da qavilis sawinaaRmdego saSualebebi BETAMETHASONE betametazoni betametazoni, celestodermi, celestoni. HYDROCORTISONE hidrokortizoni hidrokortizoni, hioqsizoni FLUOCINOLON flucinari flucinari FLUMETHASON flumetazoni lorindeni C
nervuli daboloebebis gamaRizianebeli saSualebebi
NONIVAMID+NIKOBOXIL nonivamidi+nikoboqsili finalgoni METHILSALICILLAT meTilsalicilatis kombinirebuli apizatroni preparati
programa "wamlis polisi"" 5 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani munisa da tilis sawinaaRmdego saSualebebi
BENZYL BENZOATE benzil benzoati benzocidi*, benzil benzoati. PERMETRIN permetrini nitifori, permetrini*. MALATHION malaTioni malaTioni*.
oftalmologiaSi gamoyenebuli sadiagnostiko saSualebebi FLUORESCEIN fluoresceini fluoresceini, natriumis fluoresceini.
TROPICAMIDE tropikamidi midriacili, midrumi*, tropikamidi*.
madezinficirebeli da antiseptikuri saSualebebi
CHLORHEXIDINE qlorheqidini gibiskrabi*, plivasepti*. IODINE iodi iodi HYDROGEN PEROXIDE wyalbadis zeJangi wyalbadis zeJangi Sarmdeni saSualebebi AMILORIDE amiloridi amiloridi*, puritridi. FUROSEMIDE furosemidi furosemidi, laziqsi, uriqsi. HYDROCHLORTHIAZID hidroqlorTiazidi apresini, hidralazini*, hipoTiazidi. MANNITOL manitoli maniti, manitoli. SPIRONOLACTON spironolaqtoni veroSpironi, aldaqtoni*. kaliumis Semcveli saSualebebi POTASSIUM AND MAGNEZIA kaliumisa da magniumis marilebi asparkami, panangini, kaliumis SUPPLEMENTS orotati.
kuW-nawalavis traqtze moqmedi samkurnalo saSualebani CIMETIDINE cimetidini cimetidini, tagameti, histodili. ALUMINIUM HYDROXIDE + aluminis hidroqsidi + magniumis almageli. almageli A MAGNESIUM HYDROXIDE hidroqsidi RANITIDIN ranitidini zantaki, ranitinidi, rantaki, ranifleqsi*, histaki*. PIRENZEPIN pirenzepini gastrocepini, gasterili*. METOCLOPRAMIDE metoklopramidi reglani, cerukali, ceruregi*. HYOSCINE BUTYLBROMID hioscin buTilbromidi buskopani, hioscin buTilbromidi.
programa "wamlis polisi"" 6 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani DROTAVERIN drotaverini no-Spa BISACODYL bisakodili bisadili, dulkolaqsi, laqsbene. LOPERAMIDE loperamidi imodiumi, loperamidi*. antihemoroidaluri saSualebebi
LIDOCAIN lidokaini lignokaini* ANAESTHESIN anesTezinis Semcveli kombinirebuli anestezoli preparati HYDROCORTIZONE+HEPARIN kombinirebuli preparati proqtosedili
hormonebi da antihormonebi mamakacis sasq.hormoni (androgenebi)
TESTOSTERON PROPIONATE testosteron propionati testosteroni kortikosteroidebi da maTi sinTezuri Semcvlelebi HYDROCORTISONE hidrokortizoni hidrokortizoni FLUDROCORTISONE fludrokorzoni fludrokorzoni PREDNISOLONE prednizoloni prednizoloni DEXAMETHASONE deqsametazoni deqsametazoni hipofizze moqmedi saSualebebi LUPRESSIN lupresini lupresini*, vazopresini*, BROMOCRIPTINE bromokriptini bromergoni, bromokriptini, parlodeli.
TAMOXIFEN tamoqsifeni tamoqsifeni, zitazoniumi, nolvadeqsi. MEDROXYPROGESTERONE medroqsiprogesteroni medroqsiprogesteroni oraluri kontraceptivebi
NORETHISTERONE+ETHINYLEST noreTisteroni+eTinilestradioli noreTisteroni+eTinilestradioli RADIOL ETHINYLESTRADIOL eTinilestradioli mikrofolini peroraluri antidiabeturi saSualebebi GLIBENCLAMIDE glibenklamidi maninili, daonili, gilemali. ovulaciis gamomwvevi saSualebebi CLOMIFENE klomifencitrati klomidi, klostilbegiti.
gestagenebi NORETHISTERONE noreTisteroni norkoluti, mikronori*. PROGESTERONE progesteroni progesteroni
programa "wamlis polisi"" 7 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani Tiroiduli hormonebi da antiTiroiduli saSualebebi LEVOTHYROXINE levoTiroqsini misi Semcveli l-Tiroqsini, eferoqsi, Tireokombi, kombinirebuli preparatebi Tireotomi. POTASSIUM IODIDE kaliumis iodidi kaliumis iodidi CARBIMAZOL karbimazoli karbimazoli THYREOIDIN Tireoidini Tireoidini
Sratebi da imunoglobulinebi ANTIRABIES cofis sawinaaRmdego vaqcina cofis sawinaaRmdego vaqcina HYPERIMMUNESERUM ANTITETANUS IMMUNOGLOBULIN tetanusis sawininaaRmdego tetanusis sawininaaRmdego imunoglobulini imunoglobulini DIPHTERIA ANTITOXIN difteriis antitoqsini difteriis antitoqsini DIPHTERIA SERUM difteriis Srati difteriis Srati IMMUNOGLOBULIN (HUMAN) adamianis imunoglobulini adamianis imunoglobulini TETANUS ANTITOXINE tetanusis antitoqsini tetanusis antitoqsini BOTULISME ANTITOXINE botulizmis antitoqsini botulizmis antitoqsini
oftalmologiuri antimikrobuli da anTebis sawinaaRmdego saSualebebi
GENTAMICINE gentamicini gentamicini ACYCLOVIR acikloviri acikloviri, zoviraqsi. SILVER NITRATE vercxlis nitrati vercxlis nitrati TETRACYCLINE tetraciklini tetraciklini HYDROCORTIZONE hidrokortizoni hidrokortizoni SULFACIL-NATRII sulfacil natriumi albucidi PREDNISOLONE prednizoloni prednizoloni oftalmologiuri adgilobrivi saanesTezio saSualebebiãâèêíáðèåè ñààìäñçäæèí ñàøóàêäáäáè TETRACAINE tetrakaini dikaini, tetrakaini.
gugis Semaviwroebeli da glaukomis samkurnalo saSualebebi
ACETAZOLAMIDE acetazolamidi diakarbi, acetazolamidi*. PILOCARPINE pilokarpini pilokarpini TIMOLOL Timololi aruTimoli, Timoptiki, optimoli, okupresi. ATROPINE atropini atropini TROPICAMIDE tropikamidi tropikamidi*
saSvilosnos mastimulirebeli da momadunebeli saSualebebi
ERGOMETRINE ergometrin maleti ergometrini
programa "wamlis polisi"" 8 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani OXYTOCIN oqsitocini oqsitocini, sintocinoni. bronquli asTmis sawinaaRmdego saSualebebi AMINOPHYLLINE/THEOPHYLLIN aminofilini / Teofilini diafilini*, etifilini, eufilini, Teofilini E BECLOMETAZONE beklometazoni beklazoni, bekonaza*, bekotidi, biklomati. CROMOGLICIC ACID qromoglicinis mJava qromoglicinis mJava DISODIUN CROMOGLYCAT qromoglicin natriumi intali, nalqromi*, qromoglicini*. SALBUTAMOL salbutamoli salbutamoli, albuteroli*. EPINEPHRINE epinefrini adrenalini FENOTEROL fenoteroli beroteki, partusisteni. xvelebis sawinaaRmdego da amosaxvelebeli saSualebebi POTASSIUM IODIDE kaliumis iodidi kaliumis iodidi PRENOXDIAZINE penoqsdiazini libeqsini BROMHEXINE bromheqsini bromheqsini
siTxeebi da eleqtrolitebi O.R.S peroraluri rehidrata-ciuli marili regidroni parenteraluri preparatebi GLUCOSE glukoza glukoza, deqstroza*, glukosterili*. POTASSIUM CHLORIDE kaliumis qloridi potasiumis qloridi* SODIUM BICARBONATE natriumis bikarbonati soda bikarbonati SODIUM CHLORIDE natriumis qloridi izotonuri xsnari, sodiumis qloridi, fiziologiuri xsnari, hipertonuli xsnari.
vitaminebi da mineralebi ASCORBIC ACID askorbinis mJava vitamini-?. ERGOCALCIFEROL ergokalciferoli ergokalciferoli, vitamini D NICOTINAMID nikotinamidi nikotinamidi, vitamini ? P RETINOL PALMITATE retinolis palmitati retinoli, vitamini ?A THIAMINE Tiamini bromidi vitamini B?-1 CALCIUM GLUCONATE kalciumis glukonati kalciumis glukonati VICASOL vikasoli vikasoli, vitamini ?K CALCII PANGAMAS kalcii pangamati kalcii pangamati CALCII PANTOTENAT kalcii pantotenati kalcii pantotenati RIBOFLAVINE riboflavini vitamini B?-2 PIRIDOXINE HYDROCHLORIDE piridoqsinis hidroqlo-ridi vitaminis B?-6 CYANCOBALAMINE ciankobalamini vitaminis B?-12 TOCOFEROL tokoferoli vitamini D? MULTIVITAMINS multivitamini multivitamini, askorutini,polivitamini
SeniSvna: NUnusxaSi mocemulia medikamentebi, romelTa gacema programa "wamlis polisis" mixedviT moxdeba SeRavaTebiT. CamonaTvali Sedgenilia saqarTvelos ZiriTadi medikamentebis nusxis safuZvelze da dalagebulia farmakologiuri jgufebis mixedviT. medikamentebis am dasaxelebaTa gamowera SeiZleba moxdes nebismieri formiT da nebismieri doziT. sasurvaelia wamlis gamowera programa "wamlis polisi"" 9 SeRavaTian fasebSi gasaSvebi medikamentebis nusxa saerTaSoriso saxeli savaWro saxelwodebani gamowera SeiZleba moxdes nebismieri formiT da nebismieri doziT. sasurvaelia wamlis gamowera moxdes misi saerTaSoriso saxelwodebiT, romelic siaSi mocemulia mTavruli asoebiT, wamlis gamowerisas SeiZleba isargebloT agreTve Sesabamisi savaWro saxelwodebiT. afTiaqSi avadmyofma SeiZleba miiRos wamali alternatiuli savaWro saxelwodebebiTac (siaSi moyvanili saxelwodebebis farglebSi) * - varskvlaviT aRniSnulia im preparatebis saxelwodebani, romlebic dReisaTvis jer ar aris registrirebuli saqarTveloSi, magram farTod gamoiyeneba samedicino praqtikaSi, da misi registraciis sakiTxi mogvardeba uaxloes eqvsi Tvis ganmavlobaSi
programa "wamlis polisi"" 10